Columbia  Winihtv^ity 

mti)eCit|>ofi^eto|9orfe 

^cIjooI  of  ©ental  anb  (Bval  ^urgerp 


J^eference  Eitirarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diagnosistreatmeOOnile 


THE  DIAGNOSIS  AND  TREATMENT 

OF 

DIGESTIVE  DISEASES 
N  I  LES 


THE 

DIAGNOSIS  AND  TREATMENT 

OF 

DIGESTIVE  DISEASES 


A  PRACTICAL  TREATISE  FOR  STUDENTS  AND 
PRACTITIONERS  OF  MEDICINE 


BY 

GEORGE  M.  NILES,  M.  D. 

PROFESSOR  OF  GASTROENTEROLOGY  AND  CLINICAL  MEDICINE,  ATLANTA  MEDICAL 
college;   GASTROENTEROLOGIST  to     the     GEORGIA    BAPTIST     HOSPITAL, 
WESLEY  MEMORIAL    HOSPITAL,   ATLANTA     HOSPITAL;   CONSULTING 
GASTROENTEROLOGIST  TO   THE  ANTI-TUBERCULOSIS  ASSO- 
CIATION,  ATLANTA,   GEORGIA 


WITH  1  COLORED  PLATE  AND  86  OTHER  ILLUSTRATIONS 


PHILADELPHIA 
P.   BLAKISTON'S   SON   &   CO. 

1012  WALNUT  STREET 


2-1-7 '^mi 

Copyright,  1914,  by  P.  Blakiston's  Son  &  Co. 


THE. MAPLE. PRES3. TOEK. PA 


E.   C.  THRASH,   M.   D.    and  HANSELL  CRENSHAW,  M.  D. 

TWO   RARE   SPIRITS,    WHOSE   WISDOM,   ENCOURAGEMENT, 

AND    PHILOSOPHY   HAVE   GREATLY   AIDED 

ITS   PREPARATION, 

THIS  VOLUME   IS   INSCRIBED 


PREFACE 


In  advancing  this  volume,  it  is  not  my  purpose  to  assist 
in  the  erroneous  movement  for  divorcing  gastrointestinal 
diseases  from  the  broad  field  of  internal  medicine  to  which 
they  rightfully  belong,  but  to  answer,  for  the  student 
and  busy  general  practitioner,  two  important  questions 
regarding  these  diseases,  namely,  "What  is  the  disorder?" 
and  "What  should  be  done  for  it f" 

Not  only  general  practitioners,  but  specialists  in  other 
lines,  who  find  it  necessary  to  keep  informed  in  a  general 
way  concerning  digestion  and  nutrition,  have  discussed  with 
me  what  they  desire  in  such  a  book.  Briefly  stated,  they 
need  a  compact  book,  which  shall  contain  first,  concise, 
but  easily  intelligible,  descriptions  of  the  various  reliable 
tests  for  the  objects  of  study  in  the  gastric  contents, 
intestinal  juices,  and  feces;  second,  practicable  and  least 
disturbing  methods  of  determining  the  position,  size, 
motility,  etc.,  of  the  stomach,  intestines,  and  other  abdom- 
inal viscera;  third,  a  succinct  statement  of  the  diagnostic 
methods  indicated  in  the  recognition  of  digestive  diseases; 
and,  finally,  an  exhaustive  discussion  of  both  general  and 
special  therapy  as  applied  to  these  diseases. 

This  I  have  endeavored  to  accomplish.  I  have,  how- 
ever, purposely  omitted  lengthy  arguments  of  unsettled 
etiologic  questions,  prolix  descriptions  of  rare  conditions 
which  possess  only  academic  interest,  and  the  consideration 
of  pathologic  states  of  a  purely  surgical  nature. 

On  the  other  hand,  remembering  Herbert  Spencer's 
words,  that  "To  so  present  ideas  that  they  may  be  appre- 
hended with  the  least  possible  mental  effort,  is  a  desidera- 
tum," and  recognizing  the  importance  of  economizing  the 
reader's  attention,  I  have  earnestly  labored  to  express  my- 
self in  a  clear  and  explicit  manner. 

vii 


Vlll  PREFACE 

In  the  making  of  this  work,  I  have  in  many  instances 
departed  from  the  beaten  track,  voicing  conclusions  and 
consequent  therapeutic  procedures  at  variance  with  those 
laid  down  in  some  accepted  text-books.  These  conclusions 
have  been  reached  by  years  of  study  and  observation; 
the  therapy  has  been  proved  to  my  satisfaction,  and  can 
be  proved  to  the  satisfaction  of  others  who  will  honestly 
investigate. 

I  wish  to  express  my  appreciation  and  thanks  to  the  fol- 
lowing named  gentlemen  for  various  courtesies  extended  to 
me  in  the  preparation  of  this  volume:  Dr.  Max  Einhorn, 
Dr.  George  Roe  Lockwood,  Dr.  Robert  Coleman  Kemp, 
Dr.  Anthony  Bassler,  Dr.  C.  D.  Aaron,  Dr.  A.  B.  Jamison, 
Dr.  J.  D.  Albright,  and  Dr.  J.  W.  Weinstein. 

George  M.  Niles. 


TABLE  OF  CONTENTS 

PART  FIRST 

GENERAL  DIAGNOSIS  AND  TREATMENT  OF  DIGESTIVE  DISEASES 

DIGESTIVE  DISEASES 

CHAPTER  I 

Page 

Getting  in  Touch  with  the  Patient i 

CHAPTER  II 

Diagnostic  Methods i5 

Palpation  of  the  Epigastric  and  Abdominal  Surface 29 

Examination  of  the  Abdomen  below  the  Epigastrium 35 

Transillumination  of  the  Stomach  or  Gastrodiaphany 41 

Chemic  Examination  of  the  Stomach  Contents 44 

Test-meals 44 

CHAPTER  III 

Examination  of  the  Feces 69 

Microscopical  Examination  of  the  Stools 74 

Intestinal  Parasites 79 

CHAPTER  IV 

Examination  of  the  Esophagus,  Stomach  and  Intestines  by  the 

Roentgen  Ray no 

CHAPTER  V 

Is  the  Case  Strictly  Surgical? i59 

Early  Malignant  Growths  in  the  Stomach  or  Intestines  .    .    .    .    :  160 

Late  Malignant  Growths 160 

Non-malignant  Growths  of  the  Stomach,  Pylorus  or  Duodenum  .    .  162 

Confirmed  Atony  and  Dilatation  of  the  Stomach 163 

Appendicitis,  Acute  or  Relapsing •    •    •  163 

Gastric  or  Duodenal  Ulcer 166 

Hemorrhages  from  the  Stomach  or  Upper  Alimentary  Tract .    .    .    .167 
Chronic  and  Indefinite  Ills  that  have  Resisted  all  Internal  Treat- 
ment  167 

ix 


X  CONTENTS 

CHAPTER  VI 

Page 
The  Stomach-tube 170 

CHAPTER  VII 

Gastric  Lavage 185 

Indications  for  Gastric  Lavage 185 

CHAPTER  VIII 

Various  Methods  of  Local  Treatment  of  the  Stomach,  Internal 

and  External 203 

Electricity 205 

CHAPTER  IX 

Orthopedic  Methods  of  Supporting  the  Abdominal  Walls  and 

Viscera 222 

CHAPTER  X 

Local  Treatment  of  the  Intestines 233 

Local  Applications 243 

CHAPTER  XI 
Hydrotherapy  in  Gastrointestinal  Diseases 260 

CHAPTER  XII 
Psychotherapy  in  Gastrointestinal  Diseases 282 

CHAPTER  XIII 

General  Considerations  of  Diet 315 

Chemic  Composition  of  Common  Food  Substances 325 

Artificial  Foods 336 

Duodenal  Alimentation 340 

Rectal  Feeding 344 

Recipes  for  Nutrient  Enemata 348 

Other  Methods  of  Nourishing  the  Body 349 

CHAPTER  XIV 
Drug  Therapy  in  Digestive  Diseases 351 


CONTENTS  XI 

PART  SECOND 

SPECIAL  DIAGNOSIS  AND  TREATMENT  OF  DIGESTIVE  DISEASES 

CHAPTER  XV 

Page 

Neuroses,  Motor,  Sensory,  and  Secretory 377 

Motor  Neuroses 381 

Sensory  Neuroses 384 

Secretory  Neuroses 387 

Secretory  Neuroses  of  the  Intestines 396 

General  Considerations  in  Therapy  of  Digestive  Neuroses ....  400 

CHAPTER  XVI 

The  Gastrites,  Acute  and  Chronic 403 

Acute  Gastritis 403 

Acute  Infectious  Gastritis 406 

Toxic  Gastritis 407 

Phlegmonous  Gastritis 408 

Chronic  Catarrhal  Gastritis 410 

Achylia  Gastrica 415 

Treatment  of  Chronic  Gastritis 417 

Diet  for  Chronic  Gastritis  (Ewald) 420 

Diet  for  First  Week  of  Treatment  (Einhorn) 420 

Diet  for  Chronic  Gastritis  (Friedenwald  and  Ruhrah) 42 1 

Alcoholic  Gastritis 423 

CHAPTER  XVII 

Motor  Insufficiency  and  Dilatation  of  the  Stomach 426 

Motor  Insufficiency  of  the  Second  Degree 429 

Acute  Dilatation  of  the  Stomach 435 

CHAPTER  XVIII 

Hematemesis — Ulcer  of  the  Stomach 439 

Ulcer  of  the  Stomach 440 

Treatment  of  Gastric  Ulcer 445 

Indications  for  Surgery 456 

Chronic  Erosions 457 

CHAPTER  XIX 

Tumors  of  the  Stomach — Foreign  Bodies  in  the  Stomach  ....  460 

Diagnosis  of  Cancer  of  the  Stomach 464 

Medical  Treatment  of  Gastric  Cancer 477 

Foreign  Bodies  in  the  Stomach 481 


xii  CONTENTS 

CHAPTER   XX 

Page 

Duodenal  Ulc^r — Intestinal  Ulceration — Proctitis 485 

Treatment  of  Duodenal  Ulcer 491 

Intestinal  Ulcers 492 

Proctitis 494 

CHAPTER  XXI 

Diarrhea  and  Dysentery 515 

Treatment  of  Diarrhea 521 

Dysentery 5^5 

Amebic  Dysentery 533 

CHAPTER  XXII 
Constipation ' 543 

CHAPTER  XXIII 

Intestinal  Parasites 557 

Vermes 55^ 

General  Index 57i 


PART  FIRST 

GENERAL  DIAGNOSIS  AND  TREATMENT  OF 
DIGESTIVE  DISEASES 


DIGESTIVE  DISEASES 


CHAPTER  I 
GETTING  IN  TOUCH  WITH  THE  PATIENT 

In  the  management  of  ills,  to  which  the  gastrointestinal 
tract  is  heir,  the  physician  should  never  lose  sight  of  the 
individual.  To  attempt  a  rational  treatment  of  these 
many  and  ofttimes  perplexing  manifestations  of  disordered 
digestion,  without  delving  into  the  personality  underlying 
and  permeating  them  all,  will  in  very  many  instances 
prove  disappointing  to  both  patient  and  physician. 

I  admit  that  in  the  acute  expressions  of  gross  dietetic 
errors,  routine  methods  to  cleanse  the  alimentary  canal 
and  relieve  distress  are  generally  sufficient.  These  con- 
ditions require  but  little  scientific  acumen,  the  indications 
for  treatment  being  obvious.  Such  disorders,  apart  from 
their  emergent  nature  and  the  demand  for  quick  and  in- 
telligent care,  do  not  generally  call  for  any  great  amount 
of  either  tact  or  patience  on  the  part  of  the  medical 
attendant. 

When,  however,  an  indigestion,  either  real  or  supposed, 
passes  the  acute  stage,  and  assumes  the  least  tendency  to 
chronicity,  then  it  is  that  the  whole  personality  of  the 
sufferer  becomes  involved,  and  the  digestion  alone  is  no 
longer  the  only  issue. 

When  a  patient  requests  aid  for  any  form  of  gastrointes- 
tinal discomfort,  his  complaints  should  be  received  with 
close  attention,  and  met  with  kindly  interest.  It  matters 
not  whether  the  disturbance  lies  in  the  stomach,  the  in- 


2  GETTING  IN  TOUCH  WITH  THE  PATIENT 

testines,  or  is  the  reflection  of  a  disturbed  mentality,  it 
is  a  thing  of  reality  to  the  patient;  otherwise,  he  would 
not  come  for  relief.  He  is  naturally  unable  to  differentiate 
between  important  and  unimportant  symptoms — all  are 
important  to  him;  and  a  lack  of  interest  from  the  one  to 
whom  he  has  come  for  aid  may  impair  confidence  at  the 
start,  and  greatly  handicap  the  most  worthy  efforts. 

Again,  the  attitude  of  the  physician  toward  the  patient 
should  be  as  far  as  possible  optimistic.  In  no  class  of 
diseases,  other  than  those  purely  mental,  is  there  such  a 
tendency  toward  pessimism,  low  spirits,  or  even  a  settled 
gloom,  as  in  the  digestive  troubles.  The  sour-appearing 
dyspeptic,  with  his  complaints  and  grumblings,  his  warped 
viewpoint  of  life,  and  his  mournful  introspection,  has 
become  a  familiar  and  classic  picture. 

These  sad-visaged  sufferers  nearly  always  come  with  a 
ready-made  diagnosis,  whose  basic  supports  may  be  built 
upon  the  most  nebulous  foundations,  but  who  cannot 
be  swerved  from  their  false  ideas  by  rough  tactics.  No 
matter  how  foolish  some  of  these  ideas  may  appear  to  the 
trained  intellect  of  the  medical  man,  or  how  bizarre  the 
fancies,  they  must  be  met  as  if  they  were  real  pathologic 
entities,  not  ridiculed  nor  scoffed  at. 

These  varied  symptoms  do  not  necessarily  denote  a  weak 
mentality.  It  appears  that  digestive  distress,  when  long 
drawn  out,  affects  all  grades  of  intelligence  with  an  almost 
equal  blight.  It  seemingly  spares  no  one.  Thus,  to  as- 
sume that  a  patient  is  weak  minded,  because  he  gives  way 
to  depression  and  food-fear  as  a  result  of  dyspepsia,  is 
in  the  vast  majority  of  instances  absolutely  incorrect  and 
unjust.  Furthermore,  there  are  few  cases  of  chronic 
indigestion  that  can  be  successfully  managed  by  medical 
and  dietetic  measures  alone,  if  administered  in  a  routine 
manner,  unaccompanied  by  any  moral  propulsive  power. 
The  dynamics  of  medicine  and  the  dynamics  of  mind  cannot 
be  disassociated.  It  is,  therefore,  necessary  at  the  very 
beginning  of  the  treatment  to  get  in  close  touch  with  the 


TEMPERAMENT  3 

individuality  of  the  patient;  to  discover,  if  possible,  his 
vulnerable  points  both  for  good  and  ill;  to  probe  with 
sympathetic  interest  his  hopes,  his  fears,  his  aspirations. 
Many  times  in  such  a  preliminary  investigation,  the  whole 
secret  is  bared;  the  primary  underlying  cause  is  disclosed; 
and  knowing  this,  the  indications  for  treatment  are  clear 
as  the  noonday  sun. 

Recently  there  consulted  me  a  widow,  who  complained 
of  poor  digestion  and  extreme  nervousness.  She  had  noted 
that  at  the  end  of  each  month,  as  "rent-day"  drew  near 
and  her  depleted  finances  seemed  insufficient  to  meet  her 
imperative  obligations,  her  digestion  would  become  more 
painful.  After  her  rent  had  been  paid,  she  claimed  that 
for  several  days  she  always  enjoyed  a  comparative  freedom, 
from  her  chronic  ills.  A  careless  or  unsympathetic  inquiry 
would  not  have  brought  out  these  facts,  and  the  knowledge 
of  them  enabled  me  to  relieve  both  her  suffering  body  and 
her  perturbed  mentality. 

The  temperament,  that  "climate  of  the  mind,"  as  it  is 
called  by  Dr.  Weir  Mitchell,  often  gives  important  clues, 
if  rightly  read.  To  expect  gastric  neuroses  in  phlegmatic, 
unintelligent  laborers,  who  perform  physical  toil  requiring 
no  mental  effort,  and  whose  bodies  demand  practically  all 
of  the  available  vitality,  leaving  but  little  for  the  nerves, 
would  be  foolish.  On  the  other  hand,  in  this  strenuous 
march  of  the  twentieth-century  civilization,  to  "keep  up 
with  the  procession"  requires  a  constant  tax  on  every 
bodily  and  nervous  resource,  so  that  in  the  alert  and  wide- 
awake individuals  of  middle  age,  or  younger,  it  is  sometimes 
almost  impossible  to  differentiate  between  organic  and 
neurotic  disturbances  of  digestion,  unless,  in  addition  to 
known  scientific  methods  of  diagnosis,  careful  studies  of 
both  disposition  and  temperament  are  conscientiously 
made. 

Some  of  the  most  bitter  complaints  of  various  digestive 
ills  come  from  young,  rosy  and  well-nourished  individuals, 
with  no  signs  of  cachexia,  but  with  evident  hyper-sensitive 


4  GETTING   IN   TOUCH   WITH   THE   PATIENT 

nerves.  Then  we  often  have  to  contend  with  the  young 
or  middle-aged  woman  of  good  circumstances,  of  refine- 
ment and  education,  but  who  has  nothing  to  attract  her 
thoughts  outward;  consequently,  they  stray  inward,  to 
her  hurt.  Then,  and  perhaps  the  worst,  there  is  the  suc- 
cessful business  man,  who  after  years  of  unremitting  toil, 
retires  from  active  participation  in  the  serious  affairs  of 
life,  expecting  to  enjoy  in  peace  his  well-earned  rest. 
Unfortunately,  his  dreams  are  seldom  realized.  Too  often 
his  industrious  mind,  with  no  tangible  daily  occupation, 
will  become  short-circuited  upon  his  digestion,  and  he  is 
then  liable  to  become  a  prey  to  the  many  fads  and  isms 
preached  from  the  housetops  by  the  various  cults,  each 
one  claiming  the  secret  of  health.  Such  patients  are 
frequently  in  the  incipient  stages  of  organic  disease,  the 
consequence  of  both  age  and  previous  incessant  labor, 
and  when  there  is  superimposed  an  added  complication 
of  morbid  introspection,  the  task  of  the  medical  adviser 
is  greatly  increased.  These  are  the  cases  where  the  per- 
sonality of  the  physician  counts  for  much,  and  unless 
he  can  get  in  close  touch  with  such  a  patient,  so  as  to  treat 
both  the  disease  and  the  individual,  the  results  are  generally 
unsatisfactory. 

Another  class  of  patients  who  require  careful  personal 
study  are  the  chronic  "complainers."  They  are  often 
excellent  people,  who  lead  useful  lives,  but  who  have 
imperceptibly  fallen  into  the  habit  of  magnifying  every 
epigastric  or  abdominal  sensation,  and  have  gradually 
become  convinced  that  they  have  weak  and  impaired  diges- 
tive organs.  They  can  give  no  good  reasons  for  their  un- 
ceasing complaints — they  simply  and  automatically  com- 
plain. These  again  call  for  careful  study  in  order  to  lift 
them  out  of  the  doleful  rut  into  which  they  have  un- 
consciously fallen,  and  to  place  them  upon  the  solid  ground 
of  normal  thinking,  acting  and  talking. 

In  making  up  the  anamnesis,  and  grouping  the  symptoms 
•into  a  coherent  whole,  I  have  to  an  extent  followed  the 


THE   ANAMNESIS  5 

general  plan  of  Cohnheim,  and  for  that  part  which  I  have 
utilized  I  desire  to  make  acknowledgment. 

It  is  seldom  wise  to  allow  a  patient  to  tell  his  story  in 
his  own  way.  If  allowed,  he  will  aimlessly  enumerate  all 
his  subjective  symptoms  without  regard  for  chronology, 
rhyme  or  reason,  taking  up  valuable  time  to  little  purpose. 

Usually  I  first  get  a  general  idea  of  the  family  history, 
inquiring  as  to  neurotic  ancestry,  intemperance,  possible 
malignant  or  specific  troubles,  and  manner  of  daily  life. 
The  seeds  of  many  digestive  diseases  are  sown  before  birth, 
and  numberless  unfortunates  are  ushered  into  life  with 
weak  digestive  organs,  brought  about  by  parental  infirmi- 
ties, and  fostered  by  parental  shortcomings. 

Many  times  I  have  noted  patients  with  a  history  of  poor 
digestion  dating  back  to  childhood,  who  admitted  early 
recollections  of  dyspeptic  parents,  creating  a  "dyspeptic 
environment"  from  which  the  passage  of  time  had  not 
released  them.  These  sufferers  are  deeply  imbued  with 
their  beliefs,  and  ordinary  methods  of  treatment  possess 
for  them  no  efficacy  whatever. 

Next  I  inquire  how  long  the  present  illness  has  been  in 
evidence,  together  with  the  causes  leading  up  to  it.  Such 
indefinite  statements  as  "A  long  time,"  or  "Several  years" 
mean  nothing,  and  are  without  value.  To  arrive  at  a 
definite  starting  point,  the  physician  must  learn  just  when 
the  symptoms  first  appeared,  whether  the  trouble  developed 
suddenly  or  gradually,  and  whether  it  has  been  intermittent 
or  steadily  progressive. 

Such  information  at  once  classifies  the  affection  as  acute 
or  chronic,  and  clearly  points  the  way  for  further  questions. 

Next  comes  the  inquiry  as  to  whether  the  discomfort  is 
constant  or  only  occasional.  This  is  of  importance,  because 
the  course  and  progress  of  the  trouble,  the  remissions  or 
intermissions,  may  in  themselves  name  the  diagnosis  to- 
gether with  the  indicated  treatment. 

Chronic  gastritis,  nervous  dyspepsia,  malignancies  in  or 
around  the   digestive  tract,    stenoses   or  kinks   occurring 


6  GETTING   IN   TOUCH   WITH   THE   PATIENT 

along  the  course  of  the  alimentary  canal — all  these  cause 
a  certain  amount  of  unbroken  distress.  Oh  the  other 
hand,  periodic  pains  may  raise  the  suspicion  of  duodenal 
ulcer,  gall-stones,  relapsing  appendicitis,  gastric  crises, 
gastralgia,  cyclic  vomiting,  or  one  of  the  many  forms  of 
psychic  indigestion.  It  is  especially  necessary  to  learn 
whether  these  periods  of  discomfort  are  punctuated  by  those 
of  entire  comfort  and  well-being,  or  are  simply  remis- 
sions, where  the  patient  feels  better,  but  is  not  entirely  well. 

Considerations  of  appetite  are  of  value.  Many  of  the 
most  chronic  and  persistent  alimentary  ills  flourish  right 
along  in  company  with  a  normal,  or  even  ravenous  appetite, 
and  this  will  point  to  one  of  two  conclusions — either  the 
presence  of  a  neurosis,  or  the  insistent  demands  of  a  half- 
starved  body,  tortured  by  a  long,  rigorous,  and  perhaps 
unnecessary  course  of  dieting. 

These  constant  voicings  of  "cell-hunger"  are  frequently 
the  unrealized  factors  that  make  for  the  sour  disposition 
and  clouded  mental  horizon  so  characteristic  of  the  con- 
firmed dyspeptic  who  sticks  to  a  limited  diet  for  months 
and  years. 

Should,  however,  the  appetite  be  consistently  poor,  this 
fact  may  point  to  malignant  disease,  to  a  scanty  output 
of  digestive  juices,  to  chronic,  so-called  intestinal  autoin- 
toxication, or  even  to  a  long-standing  nervous  anorexia. 

Having  disposed  of  this,  the  next  question  would  natu- 
rally be  in  regard  to  swallowing.  Apart  from  a  psychic 
difficulty,  which  may  be  caused  by  disgusting  sights  or 
thoughts  connected  with  the  food,  or  by  lack  of  saliva  to 
moisten  the  bolus,  the  latter  of  which  may  come  from  either 
bodily  or  mental  illness,  an  impediment  to  the  act  of  deg- 
lutition would  indicate  the  disease  of  either  the  esophagus 
or  cardiac  opening  of  the  stomach. 

A  violent  emotion  will  sometimes  as  effectually  inhibit 
the  power  to  swallow  as  a  mechanical  obstruction.  A 
number  of  years  ago,  I  observed  a  healthy  and  robust  man 
attempt  to  eat  a  meal  while  his  wife  was   at  the  height 


THE    ANAMNESIS  7 

of  her  first  labor.  After  several  futile  attempts,  he  de- 
sisted, saying  that  had  his  throat  been  encircled  by  a 
knotted  cord,  it  would  have  been  just  as  possible  to  swal- 
low. A  few  hours  later,  his  wife  having  been  safely  deliv- 
ered, he  had  no  trouble  in  eating  a  hearty  meal. 

An  intermittent  difficulty  might  mean  esophagismus  or 
cardiospasm,  but  a  gradual  increase  to  where  only  finely 
comminuted  food  or  liquids  can  be  forced  down  the  esopha- 
gus, especially  in  patients  past  middle  life,  would  indicate 
either  malignant  growth  or  a  gradual  tightening  cicatrix 
from  previous  ulcer.  A  stenosis  following  injury,  or  burns 
from  corrosive  substances,  can  generally  be  diagnosed  from 
the  history. 

The  possible  presence  of  an  esophageal  diverticulum 
should  be  kept  in  mind,  particularly  if  there  is  frequent 
difficulty  in  swallowing,  accompanied  by  a  sense  of  dis- 
tention and  regurgitation  of  portions  of  the  food.  The 
other  diagnostic  features  of  esophageal  diverticulum  cannot 
be  discussed  here. 

The  next  question  would  be  as  to  the  pain  or  other  un- 
comfortable sensations  which  brought  the  patient  for 
relief.  This  is  of  deep  significance,  because  a  purely 
functional  dyspepsia  never  causes  actual  pain.  There 
may  be  feelings  of  distress,  or  distention,  or  pressure,  or 
desire  to  eructate  gas,  or  even  acute  nausea,  but  as  to  pain 
in  the  strict  acceptation  of  the  term,  close  questioning 
seldom  discloses  it.  Many  patients  seem  unable  to  dis- 
tinguish the  difference  between  pain  and  other  sensory 
disturbances,  and  the  physician  should  ever  be  on  the 
alert  lest  error  creep  in. 

I  include  as  pain,  sensations  of  crampy,  colicky,  cutting, 
stabbing,  boring,  or  burning  nature,  and  not  the  various 
other  vague  and  indefinite  feelings  of  discomfort,  even 
though  they  bring  about  decided  distress. 

Another  frequent  condition  that  is  denominated  pain, 
unless  carefully  differentiated,  is  the  globus; hystericus. 
This,   though  easily  recognized,   needs  to^be  dealt  with 


8  GETTING   IN   TOUCH   WITH   THE   PATIENT 

cautiously  and  tactfully.  The  term  hysteric  is  looked  on 
with  aversion  by  all,  and  its  application  to  any  patient  is 
sure  to  excite  resentment  or  even  indignation.  Many  a 
patient  has  changed  her  doctor  in  anger  upon  being  told 
that  some  of  the  symptoms  were  hysterical,  and  few  there 
are  who  will  permit  this  supposed  stigma  to  be  mentioned 
with  equanimity.  Really,  it  is  seldom  necessary  to  inform 
a  patient  that  some  of  her  or  his  symptoms  are  hysterical, 
and  my  experience  has  taught  me  to  steer  clear  of  its  men- 
tion directly  or  indirectly. 

If  pressure  and  discomfort  alone  are  felt,  the  question 
arises  whether  they  are  constant,  or  only  appearing  after 
meals  at  irregular  or  stated  intervals.  Constant  pressure 
in  the  abdomen,  independent  of  the  meals  or  the  nature 
of  the  food,  may  indicate  a  gastric  neurosis,  pressure  from 
a  distended  intestine,  or  encroachment  upon  the  abdominal 
cavity  from  ascites  or  enlargement  of  some  of  the  abdominal 
viscera. 

A  pressure  located  in  and  around  the  epigastrium,  accom- 
panied by  fullness,  distention,  flatulence,  malaise,  heart- 
burn, regurgitation  of  sour  chyme,  and  perhaps  vertigo, 
will  excite  the  suspicion  of  a  decided  hyperchlorhydria, 
or  peptic  or  duodenal  ulcer.  It  might  be  well  to  mention, 
however,  that  this  train  of  symptoms  is  occasionally  the 
reflex  expression  of  a  chronic  appendicitis,  or  even  of  a 
disturbance  in  or  around  the  gall-bladder. 

Pressure  occurring  only  after  taking  solid  food  indicates 
chronic  gastritis,  while  if  it  is  in  evidence  after  either  solid 
or  liquid  food,  a  neurosis  may  be  thought  of. 

Should  there  be  actual  pain,  it  is  well  to  ascertain  its 
character,  and  when  and  where  it  occurs.  Should  it  be  of 
a  colicky,  cutting  or  boring  nature,  radiating  backward, 
it  may  mean  one  of  several  morbid  conditions.  If  it  re- 
curs every  few  months,  with  periods  of  comparative  health 
between,  it  may  be  cholelithiasis  or  some  form  of  gastric 
crisis.  Should  it  occur  daily  at  a  definite  time  after  eating, 
and  be  relieved  by  vomiting  or  alkalies,   it  is  probably 


THE   ANAMNESIS  9 

ulcer  or  perhaps  only  hyperchlorhydria.  Should  it  be 
relieved  by  the  escape  of  gas  or  free  evacuation  of  the 
bowels,  it  may  be  an  intestinal  colic  brought  about  by 
ordinary  constipation,'  by  excessive  protein  putrefaction, 
or  by  numerous  kinks  and  twists  found  in  ptosed  intes- 
tines. The  importance  of  visceroptosis,  with  its  train  of 
attendant  evils,  has  but  recently  been  recognized  and  only 
in  the  last  few  years  has  the  medical  profession  realized 
the  excellent  results  obtainable  by  raising  and  straightening 
out  these  twisted  and  distorted  intestines. 

Should  vomiting  alone  relieve  pain,  and  should  the 
patient  find  that  food  taken  many  hours  previously  is 
ejected,  it  would  indicate  either  a  stenosed  pylorus  or  a 
duodenal  kink  or  other  obstruction. 

The  symptom  of  vomiting,  in  any  of  its  aspects,  is  im- 
portant. Early  morning  vomiting  from  an  empty  stomach 
may  indicate  pregnancy,  alcoholic  gastritis,  or  gastrosuc- 
corrhea.  Sudden  and  explosive  vomiting  immediately 
after  eating  indicates  reflex  excitation;  a  profuse  vomiting 
of  spoiled  and  fermented  food  every  few  days  points  to  a 
dilated  stomach ;  the  vomiting  of  gastric  crises  or  the  cyclic 
form  occur  between  periods  of  good  health;  while  if  it 
comes  on  after  dietetic  indiscretions,  it  may  mean  only 
the  rebellion  of  an  insulted  stomach. 

The  condition  of  the  patient's  bowels  is  always  worth 
careful  inquiry.  A  detailed  recital  of  their  habit,  character 
of  stools,  presence  or  absence  of  mucus,  state  of  the  mucus 
in  regard  to  the  feces,  intestinal  parasites,  flatus,  and  other 
considerations,  should  never  be  omitted. 

After  these  special  symptoms  have  been  noted,  it  is  then 
in  order  to  obtain  a  grouping  of  general  symptoms,  for  now 
the  physician  can  give  them  their  proper  weight  in  making 
up  his  estimate  of  the  whole.  Great  loss  of  flesh,  progres- 
sive weakness,  anorexia  or  excessive  appetite,  abnormal 
thirst,  change  of  disposition,  troubled  sleep,  mental  de- 
pression or  irritability — all  these  to  the  observant  intellect 
of  the  careful  clinician  will  tell  their  story,  and  ofttimes  a 


lO  GETTING   IN   TOUCH   WITH   THE   PATIENT 

practically  certain  diagnosis  can  be  made  without  going 
further,  though  such  a  diagnosis  is  not  always  satisfactory. 

The  chief  gastroenterologist  of  a  busy  Jewish  clinic  in 
New  York  City  recently  confessed  that  80  per  cent,  of  the 
diagnoses  were  made  from  the  subjective  symptoms  alone. 
This  state  of  affairs  he  did  not  defend,  but  pled  the  over- 
whelming amount  of  work  to  be  accomplished  in  a  neces- 
sarily brief  space  of  time. 

Having  made  all  the  proper  inquiries  of  the  patient,  the 
physical  and  other  forms  of  examinations  are  next  in  order. 

While  some  patients  demur  at  the  necessary  disrobing, 
incident  to  a  thorough  physical  examination,  at  heart  they 
appreciate  the  interest  shown  by  the  physician.  Such 
objections  can  nearly  always  be  overcome  by  a  little  tact 
and  explanation  of  the  purpose  in  view,  and  the  more 
complete  the  examination,  the  more  confidence  will  be 
instilled  into  wavering  and  doubting  minds. 

Knowing  how  often  patients  come  with  a  self-made 
diagnosis  of  digestive  disease,  when  the  trouble  is  elsewhere, 
it  behooves  the  examiner  to  observe  carefully  the  general 
appearance  of  the  whole  body,  not  neglecting  the  facial 
expression. 

With  many,  especially  the  uneducated,  a  disturbance 
anywhere  between  the  neck  and  the  symphysis  pubis  is 
denominated  "stomach  trouble."  Not  infrequently  do  I 
have  women  with  marked  ovarian  disease,  or  men  with 
irritations  of  the  urinary  bladder,  who  confidently  lay  the 
blame  on  that  long-suffering  viscus,  the  stomach,  and  are 
with  difficulty  convinced  otherwise. 

The  appearance  of  the  skin,  its  ruddy  or  sallow  hue,  its 
firm  or  wrinkled  "feel,"  its  healthy  moisture  or  harsh  dry- 
ness, pallor,  or  cyanosis,  cachexia  or  eruption — any  of 
these  will  tell  their  story.  A  slight  erythema  of  the  backs 
of  the  hands,  which  the  patient  has  hardly  noticed,  may  fix 
the  diagnosis  of  pellagra,  while  the  bronze  color  may 
stamp  it  Addison's  disease. 

The  present  state  of  nourishment  is  also  of  the  utmost 


APPEARANCE    OF   THE   PATIENT  II 

importance,  not  only  from  a  diagnostic  standpoint,  but 
from  that  of  the  nature  of  treatment,  dietetic  or  otherwise, 
to  be  inaugurated.  Let  it  not  be  forgotten  that  some  of 
the  most  abject  and  emaciated  specimens  of  humanity 
are  brought  to  their  miserable  state  by  foolish  systems  of 
dieting.  A  very  strict  diet,  in  which  the  viands  most 
relished  are  forbidden,  is  liable  to  set  up  first  an  anorexia, 
then  a  sitophobia,  or  fear  of  food.  To  expect  the  digestive 
organs,  whose  principal  advisors  and  stimulators  are  the 
hormones,  or  psychic  incentives,  to  perform  their  best  work, 
when  every  meal  is  taken  with  indifference,  disgust  or 
gastronomic  introspection,  is  chimerical.  So,  often,  one 
after  the  other,  loved  delicacies  are  forbidden,  while  nothing 
appetizing  is  substituted,  until  the  patient  is  reduced  to 
the  verge  of  caloric  bankruptcy. 

Recently  there  consulted  me  an  intelligent  young  lady, 
who  had  for  two  years  been  gradually  reduced  in  her  food 
intake,  so  that  she  was  getting  only  about  three  hundred 
calories  daily.  She  complained  of  "sinking  spells"  in  her 
stomach,  of  weak  and  trembling  knees,  and  a  tendency  to 
cry  at  the  least  provocation.  Examination  revealed  fairly 
healthy  digestive  organs,  and  little  was  required  besides 
liberal  alimentation  to  make  her  strong  and  happy  once 
more.  Evidently  the  disorder  for  which  she  first  sought 
aid  had  long  since  disappeared,  but  the  dietetic  shadow 
still  held  on,  to  her  discomfiture. 

There  is  another  class  of  patients,  who  strenuously  insist 
on  emptying  the  stomach  at  the  first  sign  of  epigastric 
distress,  real  or  fancied.  These  are  generally  neurotic  or 
hyper-sensitive  individuals,  who  imagine  that  food  can 
exert  some  malign  effect  on  the  stomach,  if  allowed  to 
remain  there  too  long.  Without  giving  the  meal  a  chance 
to  be  chymified,  or  ejected  into  the  small  intestine,  where 
it  can  be  of  actual  service  to  their  body,  they  wildly  drink 
warm  water  or  some  emetic,  or,  worse  still,  they  contract 
the  "stomach-tube  habit,"  washing  out  the  essentials  of 
the  meal  before  it  comes  into  contact  with  any  absorptive 


12  GETTING   IN   TOUCH   WITH   THE   PATIENT 

surfaces.  Sometimes  the  obsession  takes  the  form  of  de- 
manding a  speedy  evacuation  of  the  bowels  by  some  hy- 
dragogue,  or  copious  enemas,  so  that  the  fecal  current  is 
continually  accelerated,  and  the  previously  mentioned 
condition  practically  obtains.  In  no  part  of  this  chapter 
does  its  title  apply  more  forcibly  then  to  this  class  of 
sufferers. 

The  "habitus  enteropticus,"  so  strongly  stressed  by 
Cohnheim,  while  of  some  importance,  does  not  possess  for 
me  that  overshadowing  significance.  I  constantly  observe 
instances  of  incompetence  of  the  abdominal  walls,  relaxed 
visceral  supports,  and  marked  visceroptoses  in  people  of 
normal  "habitus,"  and  I  am  forced  to  confess  that  the  con- 
clusions so  ably  advocated  by  both  Stiller  and  Cohnheim 
have  not  been  altogether  borne  out  by  my  experience. 

The  appearance  and  general  contour  of  the  abdomen  is 
most  instructive  to  the  practised  eye.  Sometimes  a  view  of 
the  abdominal  profile  will  disclose  the  full  and  wavy  line 
of  a  dilated  and  ptosed  stomach;  sometimes  the  outline  of 
a  morbid  growth.  A  relaxed  and  atrophied  abdominal 
wall  may  reveal  increased  peristalsis,  or  abdominal  stiffen- 
ing of  some  of  the  muscles.  Such  signs  are  specially  signifi- 
cant as  indicating  stenosis  of  the  pylorus,  or  of  the  colon. 

Visible  peristalsis  in  old  or  emaciated  people,  or.  in  multi- 
parous  women  of  slender  physique,  signifies  but  little,  and 
must  not  be  confounded  with  true  "peristaltic  unrest." 

The  appearance  of  the  tongue  is  fraught  with  pitfalls  for 
the  unwary,  and  too  often  it  is  accorded  undue  significance. 
Foul  and  coated  tongues  are  found  in  the  presence  of  gas- 
trointestinal disease,  and  sometimes  where  there  is  normal 
digestion.  It  would  appear  that  hasty  mastication,  coupled 
with  careless  "oral  toilet,"  is  responsible  for  most  of  the 
coated  tongues.  The  strawberry  tongue  of  scarlatina, 
the  tongue  denuded  of  its  epithelium  in  pellagra,  the  sug- 
gestive mucous  patches,  and  the  spongy  or  dry  and  glisten- 
ing tongue  of  depressed  bodily  states  have  their  import; 
and  I  should  mention  particularly  the  frequent  and  painful 


PHYSICAL   EXAMINATION  1 3 

little  aphthous  ulcers  found  on  the  tongue,  sometimes  called 
"dyspeptic  ulcers."  These  annoying  and  sometimes  oft- 
occurring  little  lesions  seem  to  really  have  some  connection 
with  a  disordered  alimentary  tract,  though  the  actual  re- 
lationship has  never  been  demonstrated.  The  appearance 
of  the  tongue  in  disordered  stomach  and  intestines  may 
be  accorded  some  corroborative  weight,  but,  with  the 
exceptions  mentioned,  should  not  be  taken  too  seriously. 

Auscultatory  or  scratching  percussion,  electric  transil- 
lumination, inflation  with  air  or  carbonic  acid  gas  have 
their  place  in  mapping  out  the  stomach  and  intestines,  but 
all  are  liable  to  fallacies.  When  practicable,  the  Roentgen 
rays  afford  the  most  satisfactory  information  concerning 
the  size,  character  and  relative  location  of  the  abdominal 
organs.  Incidentally,  these  rays  have  considerably  altered 
previous  conceptions  of  the  topography  of  this  cavity. 

In  the  vast  majority  of  cases,  intelligent  and  careful 
palpation  yields  the  most  satisfactory  and  reliable  informa- 
tion. Beginning  with  the  epigastrium,  the  palpating  fingers 
should  deliberately  and  attentively  examine,  as  far  as  pos- 
sible, the  stomach,  the  different  divisions  of  the  colon, 
the  sigmoid  flexure,  the  small  intestines  and  appendix, 
the  liver  and  gall-bladder,  the  spleen  and  kidneys,  the 
abdominal  rings,  the  rectum,  and  the  abdominal  cavity  as 
a  whole,  searching  for  tumors,  ascites  or  transpositions  of 
the  viscera. 

In  order  to  perform  this  successfully,  the  hands  should 
be  well  warmed,  the  patient  should  be  put  in  no  cramped 
or  uncomfortable  position  and  by  sympathetic  assurances 
upon  the  part  of  the  physician,  he  should  be  free  from 
trepidation  or  fright,  so  that  the  mind  will  be  at  ease,  and 
the  abdomen  properly  relaxed. 

Palpation  discloses  but  little  when  forced  upon  a  timorous 
or  terror-stricken  subject. 

Due  allowance  should  always  be  made,  in  seeking  for 
sore  or  tender  areas,  for  the  mental  attitude  of  the  patient. 
Some   give   way   to   bitter   complainings   at   the   slightest 


14  GETTING  IN   TOUCH   WITH   THE   PATIENT 

discomfort,  while  others,  with  Spartan  fortitude,  minimize 
the  most  exquisitely  painful  sensations.  The  physician 
will  simply  have  to  judge  each  case  according  to  its 
merits,  making  various  qualifications  as  indicated  by 
temperamental  infirmities. 

The  time  and  care  spent  in  studying  and  determining 
the  various  phases  of  the  patient's  character,  the  cheery 
interest  manifested,  and  the  optimism  brought  into  play, 
which  should  brighten  and  permeate  every  therapeutic 
procedure — all  these  are  the  necessary  factors  in  getting 
into  close  and  sympathetic  touch  with  the  discouraged 
dyspeptic,  and,  like  the  opening  move  in  a  campaign  by  a 
wise  commander,  will  often  decide  the  ultimate  success  or 
failure  of  the  whole  course  of  treatment. 


CHAPTER  II 
DIAGNOSTIC  METHODS 

In  the  proper  diagnosis  of  the  various  ills  and  abnormali- 
ties of  the  digestive  tract,  there  are  many  special  methods 
available.  A  careful  scrutiny  of  external  appearances,  a 
painstaking  manipulation  and  palpation,  a  proper  chemic 
examination  of  the  stomach  or  intestinal  contents,  making 
due  allowances  for  modifying  circumstances,  a  microscopic 
examination  of  these  contents  also,  together  with  an  X-ray 
examination  both  as  to  topography  and  motility — all  have 
their  helpful  place,  and  should  be  used,  when  necessary, 
by  the  conscientious  physician. 

A  brief  mention  of  some  of  the  more  easily  discernible 
points  of  interest  is  appropriate: 

The  greater  curvature  of  a  normally  distended  stomach 
lies  about  i  1/2  to  2  1/2  inches  above  the  umbilicus,  where 
the  abdominal  muscles  are  firm  and  fairly  taut.  Some 
there  are  who  possess  abnormally  large  stomachs  (espe- 
cially hearty  eaters  or  drinkers,  for  instance),  and  these 
should  not  necessarily  be  considered  as  pathologic,  unless 
noticeable  symptoms  are  also  in  evidence. 

When  a  patient  shows  atony  and  relaxation  of  the 
stomach  walls,  with  motor  insufficiency,  the  lesser  curva- 
ture in  its  normal  relation  to  the  diaphragm,  while  the 
lower  border  is  below  the  level  of  the  umbilicus,  and,  in 
addition,  complains  of  marked  gastric  symptoms,  we  may 
consider  it  a  case  of  dilatation  of  the  atonic  type.  Again, 
as  a  result  of  pylorospasm,  of  benign  or  malignant  stric- 
ture, or  any  obstruction  to  the  orderly  and  free  exit  of  the 
stomach  contents,  we  find  the  so-called  stenotic  or  ob- 
structive form  of  dilatation  of   the  stomach.     These  con- 

15 


1 6  DIAGNOSTIC   METHODS 

ditions  should  not  be  confounded  with  gastroptosis,  for  in 
the  latter  case  the  lesser  curvature  is  also  markedly  below 
its  proper  position. 

In  such  prolapsed  states,  the  suspensory  ligaments  of 
the  stomach  are  relaxed  and  inefficient,  and  the  entire 
viscus  sinks ;  occasionally  so  much,  that  the  lesser  curvature 
looks  inward  to  the  right,  and  the  greater  curvature  outward 
to  the  left.  The  pylorus  may  lie  below  the  level  of  the 
umbilicus,  rendering  a  "kink"  or  torsion  of  the  duodenum 
quite  easy  to  acquire,  and  mechanically  obstructing  the 
outlet  of  the  stomach. 

The  varieties  of  gastroptosis  and  gastric  dilatation  are 
numerous,  and  will  be  mentioned  again  in  the  discussion 
of  X-ray  methods. 

Whenever  practicable  the  patient  should  have  some  pre- 
liminary preparation  for  examination,  as  this  greatly  facili- 
tates the  task  of  the  physician.  On  the  day  or  night  pre- 
vious the  bowels  should  be  emptied  by  a  cathartic,  or  the 
lower  bowels  by  copious  enemata.  Should  there  be  much 
gaseous  distention,  the  addition  of  one  or  two  ounces  of 
milk  of  asafetida  to  the  enema  will  decidedly  aid  this. 
It  is  well  for  the  stomach  to  be  either  empty,  or  that  only 
a  light  meal  should  be  eaten  previous  to  the  examination. 

The  patient  should  be  examined  in  various  positions,  as 
may  be  indicated. 

Inspection. — As  a  general  rule  the  first  part  of  the 
examination  should  be  made  in  the  dorsal  position,  as  the 
physician  can  get  a  better  idea  of  the  general  relations  of 
the  external  abdomen  if  the  whole  surface  is  exposed  at 
one  time.  There  is  generally  no  objection  to  this  in  female 
patients,  if  the  pubic  region  is  covered  by  a  towel  or 
garment. 

In  obese  subjects,  or  those  with  much  deposition  of  fat 
in  the  abdominal  parietes,  but  little  specific  information 
can  be  gained  from  simple  inspection.  In  thin  individuals, 
however,  or  those  with  relaxed  and  attenuated  abdominal 
walls,  much  can  be  learned. 


INSPECTION  1 7 

Often  a  dilated  stomach  may  be  easily  recognized  by  its 
bulging  in  the  umbilical  or  hypogastric  region,  and  under 
these  circumstances  the  epigastric  region  is  usually  hollow 
and  depressed.  In  such  patients  the  artificial  distentions 
of  the  stomach  with  carbonic  acid  gas  frequently  discloses 
the  contour  of  that  organ,  including  the  peristaltic  waves, 
with  graphic  accuracy. 

Kussmaul  has  noted  very  active  peristaltic  movements 
in  the  dilated  stomach,  especially  of  the  stenotic  type,  the 
waves  passing  from  the  linea  alba  below  the  umbilicus  in 
an  upward  direction,  and  to  the  right  to  the  lower  margin 
of  the  liver. 

Kemp  facilitates  inspection  by  placing  the  patient  upon 
a  raised  table,  the  head  toward  the  window,  the  shades 
being  arranged  so  that  the  light  enters  on  a  plane  only 
slightly  above  that  of  the  patient,  and  directed  from  the 
head  toward  the  feet.  The  physician,  standing  toward 
the  foot  of  the  table,  and  bending  from  side  to  side,  can 
obtain  much  information  by  watching  the  play  of  shadows 
cast  by  the  inequalities  of  the  abdomen,  as  respiration 
progresses,  and  observing  the  undulations  of  the  under- 
lying organs  as  reflected  on  the  surface.  Other  interesting 
viewpoints  may  be  gained  by  standing  to  one  or  the  other 
sides,  or  even  permitting  the  patient  to  face  the  light  in  a 
semi-recumbent  position. 

In  thin  and  slender  multiparous  women,  a  gastroptosis 
and  enteroptosis  may  often  be  diagnosed  by  directing  the 
patient  to  stand  erect,  and  getting  a  side  view.  In  this 
position  the  epigastrium  will  exhibit  a  depression,  while  the 
bulging  surface  of  the  lower  abdomen  will  plainly  show  the 
presence  of  the  ptosed  viscera. 

I  have  many  times  been  able  to  follow  with  tolerable 
accuracy  the  peristaltic  waves  of  the  intestines,  while  any 
tumors  or  abnormal  inequalities  were  plainly  visible. 

Percussion  and  Auscultation  of  the  Stomach.— There  are 
many  factors  to  be  considered  in  making  out  the  size  and 
position  of  the  stomach  by  auscultation  and  percussion. 


l8  DIAGNOSTIC   METHODS 

The  findings  may  be  influenced  by  its  full  or  empty  con- 
dition, by  the  tone  of  its  walls,  by  the  character  of  its 
contents  (air,  water,  or  food),  by  the  position  of  the  pa- 
tient and  by  the  amount  of  subcutaneous  fat  present.  To 
get  the  best  results  the  stomach  should  contain  some  air, 
at  least;  and  Dehio  has  demonstrated,  both  on  living  sub- 
jects and  the  cadaver,  that  if  the  stomach  is  absolutely 
empty,  any  tympanitic  sounds  obtained  by  percussion  over 
this  viscus  come  from  the  colon  and  not  the  stomach, 
as  the  latter  is  contracted  into  the  left  concavity  of  the 
diaphragm,  and  not  being  in  contact  with  the  anterior 
thoracic  wall,  cannot  produce  any  tympany. 

Dr.  Robert  Coleman  Kemp  has  devoted  much  time  to 
the  elucidation  of  this  form  of  examination,  and  to  him  we 
owe  many  of  our  present  methods. 

The  patient  should  first  be  examined  in  the  dorsal  posi- 
tion, with  the  knees  slightly  flexed,  and  the  abdominal 
walls  relaxed  as  much  as  possible.  The  percussion  hammer 
may  be  used,  if  desired,  but  it  is  doubtful  if  the  hammer  can 
ever  equal  the  percussing  fingers  in  delicacy,  where  a  prac- 
tised touch  is  brought  into  play.  Under  ordinary  cir- 
cumstances the  borders  of  the  stomach  may  be  made  out 
with  a  reasonable  degree  of  accuracy,  though,  if  the  colon 
contains  much  gas,  confusion  may  occur  in  mapping  out 
the  lower  border  of  the  stomach.  The  percussion  sound  of 
the  colon  is  somewhat  lighter  than  that  of  the  stomach, 
and  also  lacks  some  of  the  resonance  and  clearness  of  the 
latter.  The  presence  of  food  in  the  stomach  or  feces  in 
the  colon  naturally  alters  the  sounds,  and  the  physician 
should  make  due  allowances.  It  is  well  to  map  out  the 
stomach,  and,  if  possible,  the  transverse  colon,  while  the 
patient  is  lying  down.  The  position  is  then  changed  to  a 
standing  posture,  and  the  changes  in  location  noted. 

Quite  frequently  the  presence  of  a  tumor  may  be  decided 
by  percussion  alone,  for  gaseous  collections  are  sometimes 
confounded  with  real  tumors  by  nervous  and  excitable 
individuals. 


METHODS    OF   PERCUSSION  IQ 

Auscultatory  Percussion. — This  is  a  most  satisfactory 
method  of  mapping  out  the  stomach,  and,  unless  the  patient 
is  very  obese,  is  fairly  accurate.  An  ordinary  stethoscope 
is  best  in  this  procedure,  and  the  chest-piece  should  be 
placed  firmly  upon  the  naked  surface  above  the  seventh  rib 
in  the  left  mammary  line,  or  between  the  tip  of  the  ensiform 
cartilage  and  the  left  costal  margin,  or  in  the  same  vertical 
line,  but  below  these  points.  When  decided  gastroptosis 
is  suspected,  the  "point  of  bearing"  may  need  to  be  quite 
low  on  the  median  line  of  the  abdomen.  The  physician' 
should  first  percuss  near  the  stethoscope,  lightly  tapping 
the  surface  with  a  single  finger,  until  the  characteristic 
sound  of  that  particular  stomach  is  decided.  He  should 
then  begin  well  away  from  the  stethoscope  and  gently 
percuss  in  a  straight  line  toward  it  until  by  the  change  of 
sound  he  knows  the  border  is  reached.  This  can  be  marked 
with  a  pencil  or  pen.  He  should  then  radiate  in  rather  a 
large  circle,  percussing  inward  from  each  peripheral  point, 
until  the  border  line  is  reached,  gently  marking  the  points 
as  located.  In  this  manner  the  stomach  can  be  quickly  and, 
under  ordinary  circumstances,  satisfactorily  mapped  out. 
The  operator  should  remember  that,  when  dilated  or  mis- 
placed, the  tendency  of  the  stomach  is  for  the  greater  bulk 
to  lie  to  the  left  of  the  median  line,  though  occasional 
cases  of  dilation  yield  a  tympanitic  sound  quite  a  distance 
to  the  right  of  the  abdomen. 

In  rare  instances  percussion  gives  valuable  information 
concerning  a  tumor  of  the  stomach  wall,  but,  if  facilities 
for  X-ray  examination  are  available,  the  latter  is  much 
more  dependable. 

Scratch  Method  of  Auscultatory  Percussion. — This 
method,  which  was  originated  by  Kemp,  has  a  field  of 
usefulness.  The  stethoscope  is  placed  upon  the  abdomen, 
as  in  the  previous  method,  and  the  surface  is  lightly 
scratched  by  the  middle  finger  in  about  the  same  way  as 
the  light  percussion.  The  stomach  tympany  can  be  fairly 
well  brought  out  in  this  way. 


20  DIAGNOSTIC   METHODS 

"Flicking  percussion"  is  employed  by  some,  but  has 
nothing  special  to  commend  it. 

Inflation  of  the  Stomach  with  Carbonic  Acid  Gas. — Under 
proper  conditions  this  is  a  useful  adjunct  to  other  means  of 
outlining  the  stomach  walls.  It  is  especially  useful  in  thin 
subjects  with  relaxed  abdominal  walls,  and  of  little  use  in 
obese  individuals,  or  those  with  rigid  abdominal  parietes. 

Two  ordinary  glasses,  each  full  of  water  are  needed.  In 
one  is  dissolved  about  a  dram  of  tartaric  acid;  in  the  other 
about  the  same  amount  of  bicarbonate  of  soda.  These 
two  solutions  are  to  be  drunk  quickly,  one  after  the  other, 
and  the  patient  instructed  to  lie  down  quietly  with  the 
mouth  closed.  The  inflation  follows  promptly,  the  stomach 
contour  becoming  plainly  visible. 

This  method  is  contraindicated  when  there  has  been  a 
recent  hemorrhage,  when  ulcer  or  cancer  is  present  in  the 
stomach,  or  in  advanced  arteriosclerosis. 

A  few  observers  have  advocated  inflating  the  stomach 
with  air,  either  with  a  Davidson  syringe  or  a  double  bulb. 
A  stomach  tube  is  flrst  introduced  through  the  cardia,  and 
the  air  is  then  pumped  in  ad  libitum.  Some  advocates  of 
this  method  claim  that  the  operator  can  tell  with  tolerable 
exactness  just  how  much  air  is  being  pumped  in,  by  keeping 
account  of  the  compressions  of  the  bulb.  To  say  the  least, 
this  is  problematical. 

Outlining  the  Stomach  by  the  Use  of  Water. — Dehio 
has  investigated  this  method  quite  thoroughly,  and  by  its 
intelligent  use  much  can  sometimes  be  learned.  The 
patient  is  first  percussed  over  the  stomach,  with  that  viscus 
empty,  and  the  patient  in  a  standing  position.  The  phy- 
sician then  administers  about  8  ounces  of  moderately  cold 
water,  and  percusses  the  area  of  dulness.  This  water  is 
followed  up  by  several  more  glasses,  each  time  noting  the 
percussion  results.  The  patient  then  assumes  the  recum- 
bent position,  and  if  tympanites  is  in  evidence  where  dulness 
formerly  appeared,  it  is  proof  positive  that  the  former  area 
of  dulness  corresponded  to  the  stomach. 


OUTLINING   THE    STOMACH  21 

Occasionally,  in  marked  atony,  dilatation,  or  ptosis,  a 
single  glass  of  water  will  cause  appreciable  dulness  below 
the  umbilicus.  This  method  is  not  applicable  in  stout 
patients,  or  where  there  is  fecal  accumulation  in  the  colon. 

There  are  many  other  methods  of  locating  and  delimiting 
the  stomach,  some  of  which  are  extremely  complicated 
but  not  very  practical.  A  few  will  simply  be  mentioned, 
though  scant  space  will  be  accorded  them.  Leube  intro- 
duces a  stiff  sound  and,  by  moving  it  about  in  the  stomach, 
determines  the  boundaries  by  touch.  In  suspected  ulcer, 
cancer  or  erosions  of  any  sort,  this  would  be  dangerous. 
Moreover,  a  method  which  is  comparatively  safe  in  skilled 
hands  might  subject  the  patient  to  grave  risk  in  unpractised 
ones. 

Some  go  so  far  as  to  inflate  the  stomach  with  carbonic 
acid  gas,  while  a  double  quantity  is  injected  into  the  large 
intestine  through  a  colon  tube.  It  is  expected  that  the 
different  pitches  of  sound  between  the  colon  and  stomach 
will  mark  the  limits  of  each.  This  has  been  tried  by  me  a 
number  of  times  without  satisfaction. 

Kemp's  stomach  whistle,  in  which  a  little  whistle  is 
attached  to  the  end  of  a  stomach  tube,  and  the  sound 
produced  by  short,  quick,  compressions  of  a  Lockwood 
bulb  inserted  into  the  other  end,  is  another  novel  method. 
This  is  quite  interesting,  and  in  practised  hands  may  be 
useful.     It  will  hardly,  however,  come  into  general  use. 

Splashing  and  Gurgling  Sounds. — These  sounds  may  be 
elicited  when  both  air  and  fluid  are  in  the  stomach,  depend- 
ing largely  on  the  state  of  the  stomach  walls.  Some 
students  of  this  subject  consider  such  sounds  as  of  no 
practical  significance,  other  than  denoting  atony  or  relaxa- 
tion of  the  stomach. 

Some  dexterity  is  required  to  produce  these  sounds 
without  discomfort  to  the  patient,  and  the  physician  should 
be  gentle  in  the  manipulations.  The  sounds  are  best 
demonstrated  by  rapidly  tapping  with  the  tips  of  two  or 
three  fingers,   but  without  entirely  removing  them  from 


22  DIAGNOSTIC   METHODS 

the  abdominal  surface.  The  patient  should  always  be 
in  the  dorsal  position  with  the  abdominal  walls  freely 
relaxed.  Sometimes  rather  energetic  manipulation  is  re- 
quired, and  both  hands  may  be  brought  into  play,  shaking 
the  two  sides  well  until  the  splashing  is  plainly  heard.  In 
some  individuals  there  is  at  frequent  intervals  more  or  less 
splashing,  denoting  no  special  pathologic  condition.  When 
it  is  found  several  hours  after  a  test  meal,  or  found  in  the 
morning  hours  before  any  food  or  water  has  been  taken,  it 
certainly  denotes  an  abnormality. 

When  well  brought  out,  the  splash  is  quite  a  rehable 
diagnostic  sign  as  to  the  position  of  the  lower  border  of  the 
stomach,  and  it  can  be  easily  verified  by  changing  the  posi- 
tion of  the  patient,  noting  the  varying  location  of  the  splash 
with  each  change. 

I  have  occasionally  found  subjects  with  hyperesthetic 
abdominal  surfaces,  who  could  not  bear  this  manipula- 
tion, and  whose  rectus  muscles  would  become  so  rigid  that 
no  sound  could  be  elicited.  These  are  unsuitable  for 
this  test,  and  the  time  may  be  put  to  better  use  in  other 
directions. 

Deglutition  Sounds. — These  were  first  described  by 
Meltzer,  and  in  the  last  few  years  have,  with  the  aid  of  the 
X-rays,  become  a  diagnostic  aid  of  considerable  value. 
The  deglutition  sounds  are  the  first,  or  the  sound  heard 
as  the  fluid  enters  the  esophagus;  and  the  second,  which 
follows  about  seven  seconds  later.  Both  may  be  heard  by 
placing  the  stethoscope  over  the  ensiform  cartilage,  though 
the  second  sound  is  more  distinct.  In  certain  or  suspected 
esophageal  or  cardiac  obstruction,  these  sounds  are  both 
significant  and  helpful.  If  both  sounds  are  absent,  there 
is  probably  a  decided  stricture  of  the  esophagus;  while  if 
the  second  sound  is  delayed,  some  obstruction  to  the  orderly 
progress  of  food  or  liquid  is  assured. 

It  is  most  interesting  and  instructive,  when  a  fluoro- 
scopic examination  is  available,  both  to  listen  to  the 
deglutition  sounds,  and  to  watch  the  causes  of  these  sounds. 


ESOPHAGOSCOPY 


23 


The  patient  is  given  some  milk,  to  which  bismuth  has  been 
added,  and  ordered  to  hold  it  in  the  mouth  until  told  to 
swallow.  Everything  being  ready,  the  X-ray  is  projected 
through  his  neck,  and  carried  down  as  he  swallows,  while 
simultaneously  the  observer  is  listening  and  watching 
through  the  fluoroscope.  Unless  the  physician  is  accus- 
tomed to  the  sounds  of  the  X-ray  machine,  he  may  become 
confused  by  the  two  sounds.  If,  however,  he  will  keep 
the  stethoscope  closely  pressed  in  the  ears,  and  his  auditory 
attention  fixed  upon  the  deglutition  sounds,  he  will  soon 
be  able  to  hear  them  satisfactorily. 

Various  other  sounds  in  and  about  the  stomach  have  been 
investigated,  some  of  them  seemingly  for  curiosity  alone. 
Some  have  claimed  to  be  able  to  hear  "dripping  sounds" 
as  the  fluid  coursed  along  the  stomach  walls,  but  this  is 
open  to  doubt.  The  succussion  sound,  produced  by 
energetically  shaking  the  whole  body,  is  of  no  account  as 
a  diagnostic  help. 

Gurgling  sounds  in  the  stomach  may  be  brought  about  by 
the  contracting  of  its  walls  on  mixed  contents  of  fluid  and 
gas.  These  sounds  are  sometimes  weird  and  disquieting 
to  the  patient,  but  have  no  fixed  diagnostic  significance. 

Esophagoscopy. — Efforts  to  examine  the  esophagus,  and 
through  it,  the  stomach,  have  been  made  for  over  a  hundred 
years.  In  1807  Bozini  directly  examined  the  upper  end  of 
the  esophagus,  and  since  that  time  many  other  investi- 
gators have  industriously  attempted  to  perfect  and  utilize 
this  method  of  diagnosis. 

For  several  reasons  esophagoscopy  will  probably  never 
become  popular  or  widely  employed.  It  is  uncomfortable 
to  the  patient ;  there  is  often  an  element  of  danger  attached 
to  its  use,  unless  in  skilled  and  practised  hands;  and  the 
slight  view  of  a  portion  of  the  interior  of  the  stomach  which 
may  at  best  be  obtained  is  generally  unsatisfactory. 

There  are  two  kinds  of  instruments  for  the  purpose:  the 
older  ones,  in  which  the  illumination  is  thrown  down  the 
tube  from  the  outside   (Mikulicz,   Rosenheim) ;   and  the 


24  DIAGNOSTIC   METHODS 

more  recent  ones,  which  have  Httle,  "cold"  electric  lamps 
on  the  distal  end  (Einhorn,  Jackson).  In  1906  Jackson 
improved  upon  Einhorn's  instrument,  and  brought  out 
one  in  which  the  interior  of  the  stomach  could  be  observed 
rather  better.  This  instrument,  besides  being  larger  than 
previous  ones,  contains  an  auxiliary  tube  for  the  drainage 
and  suction  of  the  secretions.  In  addition.  Dr.  Jackson 
devised  several  accessories,  intended  to  map  the  stomach  or 
esophageal  walls,  to  make  applications,  or  to  remove  foreign 
bodies. 

To  quote  Dr.  Jackson,  who  deserves  more  consideration 
along  this  line  than  any  other  observer,  I  will  use  the  fol- 
lowing: "The  explorable  area  varies  in  the  normal  adult 
stomach  from  one-half  to  three-quarters  of  the  total  mucous 
membrane,  the  field  being  considerably  larger  in  infancy, 
dilatation,  or  prolapse.  Careful  attention  to  two  points 
eliminates  most  of  the  difficulties  in  gastroscopy :  The  first 
of  these  is  that  profound  anesthesia  is  essential  (in  the 
esophagus  the  use  of  cocain  is  preferred)  since  when  the 
tube  enters  the  stomach  straining  and  retching  are  un- 
controllable, annoying,  and  dangerous;  the  second  point 
is  the  position  of  the  patient,  which  is  the  most  favorable 
one  in  bringing  the  mouth,  pharynx  and  esophagus  into  a 
straight  line.  To  accomplish  this  the  patient  is  drawn 
forward  until  the  tops  of  his  shoulders  clear  the  table  by 
from  4  to  6  inches,  and  the  mouth  gag  is  inserted  on  the 
left  side.  The  assistant  is  placed  on  the  right  side  of  the 
patient's  head  on  a  stool  of  appropriate  height,  as  though 
on  a  side-saddle,  his  right  leg  beneath  him  in  the  kneeling 
position,  his  left  foot  supported  on  a  stool  26  inches  lower 
than  the  top  of  the  table.  His  right  forearm  is  passed 
beneath  the  patient's  neck,  supporting  it,  his  right  hand 
grasps  the  mouth  gag,  drawing  it  strongly  at  or  in  front  of 
the  bregma,  bending  it  backward  and  exerting  a  certain 
degree  of  upward  pressure.  The  foregoing  points  having 
received  attention,  certain  difficulties  remain.  They  lie, 
however,  altogether  above  or  opposite  the  cricoid  cartilage, 


ESOPHAGOSCOPY  2$ 

and  are  surmountable  with  slight  practice.  Mikulicz 
determined  i  point,  namely,  that  a  gastroscope  must  be 
rigid.  Rosenheim  went  a  step  further,  and  said  that  it 
must  not  only  be  rigid,  but  should  be  straight;  now  I 
think  we  are  ready  to  add  four  more  dicta:  i.  Optic  appa- 
ratus must  be  abandoned.  2.  The  tube  must  be  passed 
by  sight.  3.  The  stomach  must  be  examined  in  a  collapsed 
state,  to  permit  of  mopping,  palpation  with  instrument, 
probing,  and  combined  endoscopy  and  external  palpation. 
4.  General  anesthesia  is  indispensable  to  prevent  con- 
tractions of  the  diaphragm  which  clamps  the  tube,  render- 
ing exploration  impossible. 

"The  instrument  with  the  obturator  in  situ  is  dipped  in 
warm  water,  or  better,  thoroughly  lubricated  with  glycerin. 
The  esophagoscope  may  be  introduced  without  the  employ- 
ment of  a  general  anesthetic,  although  this  is  always  pref- 
erable (the  fear  of  the  patient  from  the  looks  of  the  in- 
strument, and  the  distress  incident  to  its  passage  makes  a 
general  anesthetic  almost  essential  in  most  instances). 
Should  it  not  be  used,  the  patient  sits  in  a  backed  chair 
with  head  thrown  back  and  face  toward  the  ceiling.  The 
instrument  is  pushed  into  the  esophagus  without  exerting 
any  force,  and  introduced  the  length  of  the  esophagus. 
The  obturator  is  then  withdrawn,  the  lamp  lit,  and  in- 
spection begins  and  continues  while  the  tube  is  being 
withdrawn.  In  stomach  observations,  it  should  be  recalled 
that  the  most  important  regions  of  the  organ  for  the  site  of 
pathologic  lesions,  the  pyloric  and  lesser  curvature — are  not 
accessible  to  vision  through  the  tube;  and  thus,  that  if 
nothing  abnormal  was  noted  in  as  much  of  the  gastric 
mucosa  as  would  be  seen,  that  serious  disease  may  still 
exist  in  these  inaccessible  regions.  Both  instruments 
should  not  be  used,  excepting  where  a  diagnosis  cannot 
possibly  be  made  by  the  other  well-known  methods^ 
and  only  when  for  existing  reasons,  a  diagnosis  is  important 
to  be  obtained  quickly.  It  should  not  be  used  in  esophageal 
or  gastric  ulcer  or  phlegmonous  gastritis,  and  it  should  be 


26  DIAGNOSTIC   METHODS 

recollected  that  serious  stomach  disease  may  exist  in  the 
walls,  or  extra-gastric  of  those  areas,  exploration  of  which 
might  not  show  its  presence  on  the  mucosa  side.  Its 
field  of  usefulness  is  to  make  or  confirm  the  existence  of 
early  malignant  disease  in  the  esophagus  or  stomach 
(carcinoma  and  sarcoma),  to  remove  foreign  bodies  from 
both  organs,  and  to  diagnose  and  possibly  remove  papil- 
lomata  or  polypi  from  the  stomach.  In  my  experience, 
better  results  in  examining  the  pyloric  region  are  obtained 
in  women  than  in  men ;  this  I  believe  is  due  to  the  fact  that 
in  women  the  vertical  stomach  is  more  commonly  met  with." 

As  the  secretions  in  the  esophagus  and  stomach  are  so 
frequently  in  the  way,  and  exercise  such  a  disconcerting 
effect,  obtruding  as  they  do  just  as  the  operator  is  about 
to  obtain  valuable  information,  it  is  well  to  administer  to 
the  patient  two  hours  before  using  the  instrument  a  full 
dose  of  morphin  and  atropin,  or  atropin  alone,  to  partly 
dry  up  some  of  these  secretions.  As  a  confusing  factor 
in  the  use  of  long  tubes  is  the  reflected  light  on  its  interior, 
Bassler  has  slightly  modified  the  Jackson  instrument  by 
having  the  interior  of  the  distal  end  oxidized  or  painted 
black  for  a  distance  of  about  15  centimeters.  By  the 
existence  of  this  darkened  zone,  a  darker  circle  is  seen  about 
the  tissue  at  the  end  opening  separating  this  from  the  reflex 
of  light  nearer  the  eye. 

The  above  somewhat  detailed  description  will  convince 
the  reader  that  the  esophagoscope  and  gastroscope  are  not 
instruments  for  the  inexperienced  or  amateurs,  and  the 
physician  should  be  chary  in  attempting  to  employ  them 
unless  he  has  received  some  special  instruction,  or  feels 
that  the  need  is  very  urgent.  I  have  in  more  than  one 
instance  known  of  almost  irreparable  damage  being 
inflicted  by  the  use  of  these  instruments  in  hands  more 
zealous  than  experienced,  and  I  trust  this  caution  will  be 
heeded. 

Esophageal  Sounds  and  Bougies. — These  instruments  are 
most  useful  in  locating  foreign  bodies  in  the  esophagus  or 


ESOPHAGEAL  STRICTURE  27 

cardia,  diagnosing  and  stretching  strictures,  and  deter- 
mining the  presence  of  diverticula  extending  from  the 
esophagus. 

There  are  numerous  shapes  and  forms  of  these  instru- 
ments, some  not  being  safe  nor  practical.  In  simple 
stricture  of  moderate  degree  the  hard-rubber  sounds  with 
rounded  olive  tips  are  sufficient.  Occasionally,  when  the 
obstruction  is  slight,  a  rather  rigid  stomach-tube  will  an- 
swer, as  it  is  quite  safe.  Often,  after  a  stricture  has  been 
well  dilated,  the  passing  of  an  ordinary  stomach-tube  at 
stated  intervals  will  be  quite  sufficient  to  keep  the  esoph- 
agus open. 


iiiiii*ifni 


«]^^ 


Fig.  I. — -Esophageal  electrode,  which  has  different  sized  olives  and  which  can 
also  be  used  as  an  esophageal  bougie.     (Bassler.) 

Several  years  ago  I  was  consulted  by  a  lady  of  fifty- 
eight  years,  who  could  swallow  nothing  but  liquid  food,  and 
that  slowly  and  with  difficulty.  Examination  disclosed  a 
fairly  tight  stricture,  which  was  dilated  easily.  After  a 
few  dilations  she  could  eat  any  kind  of  food  she  desired, 
if  only  it  was  well  masticated  or  pulverized.  Since  then 
I  have  passed  a  20  English  tube  at  intervals  of  ten  days  or 
two  weeks,  finding  this  entirely  adequate  to  keep  her 
esophagus  freely  open. 

A  convenient  form  is  a  sound  with  a  single  coiled-wire 
or  whalebone  shaft  and  a  number  of  olives  of  different 
sizes.  If  the  shaft  is  too  long  to  be  conveniently  carried 
it  may  be  obtained  in  jointed  form.  These  olives  are 
sufficient  for  any  permeable  stricture,  but  occasionally 
those  are  found  that  are  so  tight  and  tortuous  that  they 


28 


DIAGNOSTIC    METHODS 


cannot  be  penetrated.  Under  these  circumstances  Plum- 
mer  has  devised  an  ingenious  method.  The  patient  is 
directed  at  night  to  swallow  3  yards  of  buttonhole  silk 
twist,  with  the  assistance  of  water  drunk  to  facilitate 
the  passage  of  the  thread.  The  following  morning  he  is 
directed  to  swallow  three  more  yards  of  the  continuous 
thread,  and  if  there  is  an  opening  through  the  stricture  or 
diverticulum,  the  thread  will  go  into  the  stomach  and  on 


Fig.  2. — Gastrotomy  for  impermeable  stricture  of  esophagus  following  acci- 
dental ingestion  of  acid.  Patient  wears  a  silver  tube  held  in  place  by  straps,  and 
occluded  by  a  cork  stopper.  Patient  in  good  health  about  fourteen  years  after 
operation.     (Operation  performed  by  late  Dr  W.  S.  Armstrong.) 


into  the  bowel,  and  will  be  firmly  enough  fixed  to  stand 
considerable  traction.  Over  this  thread  a  special  form  of 
perforated  olive  is  passed,  and  with  the  thread  as  a  guide, 
strictures  that  are  other  wise  impermeable,  may  be  safely 
penetrated;  and  by  gradually  increasing  the  sizes  of  olives, 
be  satisfactorily  dilated. 

Without  a  guide  it  is  unsafe  to  use  much  force  in  at- 
tempting to  penetrate  or  enlarge  a  tight  or  strictured  esoph- 
agus. The  operator  should  be  careful  to  use  but  moderate 
force,  and  when  his  sense  of  touch  does  not  assure  him 


PALPATION  29 

that  he  is  in  the  esophageal  channel,  he  should  cautiously 
withdraw,  and  progress  with  the  greatest  caution.  In- 
expert or  careless  handling  of  esophageal  bougies  is  fraught 
with  danger. 

These  bougies  should  never  be  used  in  the  presence  of 
aneurysm  of  the  thoracic  aorta  or  recent  hematemesis. 
In  malignant  growths  on  or  about  the  esophagus  or  cardia, 
also,  they  should  be  employed  only  under  most  urgent  need, 
and  with  the  utmost  care. 

PALPATION  OF  THE  EPIGASTRIC  AND 
ABDOMINAL  SURFACE 

The  importance  of  thorough  and  intelligent  palpation  of 
the  abdomen  as  an  aid  to  understanding  pathologic  con- 
ditions within  cannot  be  overestimated.  The  tips  of  edu- 
cated fingers  and  the  palms  of  responsive  hands  can  carry 
to  the   mind's  eye  a  picture  both  graphic  and  accurate. 

The  patient  should  sufficiently  disrobe  so  that  the  whole 
surface  from  the  thorax  to  the  symphysis  pubis  can  be 
easily  reached.  To  attempt  an  examination  with  a  limited 
surface  available,  or  a  small  area  at  a  time  is  both  un- 
satisfactory and  unscientific. 

One  word  of  admonition  is  appropriate  here :  the  physician 
should  be  sure  that  his  hands  are  warm — comfortably 
warm  to  the  patient.  Nothing  is  more  provocative  of 
resentment  of  the  abdominal  muscles,  or  more  perturbing 
to  the  patient,  than  cold  or  clammy  hands  upon  this  sen- 
sitive portion  of  the  human  body. 

The  patient  should  generally  be  placed  in  the  recumbent 
position,  first  on  the  back,  and  in  other  positions  as  the 
examination  progresses.  The  hand  should  be  gently  but 
firmly  placed  upon  the  abdominal  surface,  and  permitted 
to  remain  quietly  for  a  brief  space  of  time,  or  until  the 
abdominal  walls  and  muscles  become  accustomed  to  its 
presence.  It  is  well  also  to  assure  the  patient  that  no 
pain  of  consequence  will  be  inflicted,  so  that,  as  far  as 


30  DIAGNOSTIC   METHODS 

possible,    the    element    of    apprehension    and    consequent 
tension  may  be  eliminated. 

The  palpation  is  made  with  a  rotary  pressing  movement, 
permitting  the  hand  to  slide  smoothly  over  the  skin  from 
one  part  of  the  abdomen  to  another.  A  steady,  firm,  press- 
ing movement,  is  much  preferable  to  jabbing  the  fingers 
down  into  the  soft  yielding  surface.  By  this  means  it  is 
possible  to  press  the  hand  deeply  into  the  abdomen,  and 
to  detect  deep-seated  pathologic  lesions  of  appreciable 
size.  If  thought  necessary,  the  knees  should  be  drawn  up, 
and  moderately  deep  and  steady  breathing  should  be  en- 
couraged. It  is  also  well  for  the  physician  to  make  an 
occasional  remark,  or  to  engage  the  patient  in  desultory  bits 
of  conversation,  so  as  to  draw  his  mind  from  the  examina- 
tion. This  is  especially  appropriate  in  a  hysteric  or  neu- 
rotic patient,  otherwise  the  objective  findings  are  apt  to 
be  warped  and  biased  by  the  patient's  previously  formed 
conclusions.  During  the  various  manipulations  the  physi- 
cian should  carefully  note  the  facial  expression,  as  certain 
areas  are  palpated,  for  in  no  class  of  disorders  than  those 
incident  to  the  digestive  system  are  the  lights  and  shadows 
of  the  countenance  more  suggestive.  If  by  these  means 
sufficient  abdominal  relaxation  cannot  be  obtained,  the ' 
patient  may  be  put  in  a  warm  bath,  or  even  undergo  com- 
plete anesthesia. 

In  the  first  examination,  should  the  stomach  or  intestines 
be  distended  with  gas,  or  should  scybalous  masses  be  in 
evidence  along  the  course  of  the  intestinal  channel,  these 
facts  should  be  noted,  and  another  examination  be  made 
after  these  factors  are  removed.  "The  various  areas  of 
the  abdomen  should  be  systematically  explored,  beginning 
first  with  the  location  of  the  stomach,  then  the  small  in- 
testine, the  ileocecal  valve,  the  colon,  and  finishing  with 
the  marginal  or  deep  organs,  such  as  the  liver,  gall-bladder, 
spleen,  kidneys,  etc.  In  examining  the  lateral  portion  of 
the  abdomen,  both  hands  should  be  employed,  the  under 
one  sustaining  the  lumbar  region,  while  the  upper  makes 


PALPATION  31 

pressure  upon  it  to  note  the  character  and  consistency  of 
the  intervening  tissues"  (Bassler). 

It  is  well  to  change  the  position  of  the  body  from  time 
to  time,  observing  the  difference  in  position  of  the  various 
organs.  In  relaxed  abdominal  supports,  there  may  be  a 
variation  of  several  inches  in  the  position  of  some  of  the 
organs,  and  Dehio's  methods  of  mapping  out  the  stomach 
by  the  aid  of  drinking  one  or  more  glasses  of  water  are 
appropriate.  The  spleen  or  movable  kidneys  may  be 
palpable  in  a  semi-sitting  or  knee-chest  position,  when  they 
cannot  be  located  in  the  dorsal. 

To  find  a  movable  kidney,  I  prefer  the  following  method : 
with  the  patient  on  his  back  and  in  a  partly  sitting  posture 
(nearly  45  degrees),  I  direct  him  to  make  a  deep  inspiration, 
and  firmly  grasp  the  wall  of  the  abdomen  close  under  the 
rib  with  my  thumb  in  front  and  the  other  four  fingers 
behind  in  the  lumbar  region.  Holding  this  grip,  I  slowly 
put  the  patient  in  the  recumbent  position,  directing  him 
at  the  same  time  to  breathe  out  fully.  As  this  is  done  the 
kidney  will  be  felt  to  slip  upward  with  somewhat  of  a  jerk, 
while  the  patient  may  experience  rather  a  disagreeable 
sensation  caused  by  the  kidney  being  pressed  upon.  In 
obese  patients  it  is  sometimes  necessary  to  turn  them  partly 
on  the  side,  or  even  to  follow  up  this  manipulation  in 
several  angles  of  position. 

In  the  examination  of  women,  palpation  of  the  abdomen 
should  be  supplemented  when  possible  by  pelvic  and 
vaginal  investigation,  for  ofttimes  many  symptoms  attrib- 
uted to  the  digestive  system  may  be  in  reality  reflexes 
from  gynecologic  disturbances. 

It  is  well  also  to  examine  the  anus  and  rectum,  and,  if 
thought  advisable,  the  sigmoid  may  be  explored.  Many 
times  have  I  found  in  these  unsuspected  tracts  the  crux  of 
the  whole  situation. 

Tenderness  in  the  Epigastrium.— In  thin  and  nervous 
subjects,  particularly  women,  tenderness  will  nearly  always 
be   elicited  by   deep   pressure  in   the   epigastrium.     This 


32  ■  DIAGNOSTIC   METHODS 

comes  from  the  celiac  plexus,  and,  in  the  absence  of  other 
symptoms,  is  of  no  significance.  The  upper  portions  of 
the  recti  are  often  tender  after  hard  exercise  or  stress  of 
coughing  or  vomiting.  The  fact  that  the  tenderness  is  in 
the  abdominal  wall  instead  of  the  underlying  organs  may 
be  proved  by  pinching  up  the  muscles  laterally  when  they 
are  relaxed,  and  this  is  a  fact  well  worth  proving  in  many 
instances.  Epigastric  tenderness  may  also  be  due  to  dila- 
tion of  the  right  ventricle,  to  pleuritis,  to  acute  or  chronic 
affections  of  the  liver  or  gall-bladder,  and  to  subphrenic 
abscess.  There  are  obviously  tender  areas  in  gastric 
cancer  or  ulcer  of  any  extent,  and  in  many  there  is  a  hyper- 
esthetic  condition  of  the  epigastrium  at  all  times.  Chronic 
or  acute  gastritis,  arsenical  poisoning,  gastralgia,  phos- 
phorus poisoning,  or  chronic  pancreatitis  may  be  expressed 
in  epigastric  tenderness,  and  all  these  should  be  considered 
when  this  symptom  is  present.  In  catarrhal  states,  ten- 
derness is  usually  diffuse  over  the  gastric  region,  and, 
except  in  acute  gastritis,  is  not  accompanied  by  much 
resistance  of  the  walls.  "In  the  local  neurotic  and  gas- 
troptotic  cases  the  tenderness  is  usually  confined  in  an  area 
just  below  the  ensiform  about  the  size  of  the  palm  of  the 
hand,  and  as  a  rule  is  not  accompanied  by  resistance" 
(Bassler). 

The  tenderness  of  gastric  and  duodenal  ulcer  is  generally 
sharply  demarked,  is  situated  below  the  ensiform  to  the 
right  or  left  of  the  median  line,  and  is  generally  accompanied 
by  a  quick  and  lively  resistance.  The  same  may  be  said 
of  unfavorable  post-ulcer  conditions,  though  the  resistance 
is  not  so  act  ve,  nor  the  line  of  pain  so  well  demarked. 
The  tender  spot  associated  with  a  duodenal  ulcer  is  fre- 
quently to  the  right  of  the  median  line,  while  that  of  ulcer 
of  the  stomach  is  to  the  left.  This,  however,  should  not 
be  taken  too  literally,  as  quite  a  number  of  gastric  ulcers 
have  manifested  a  tender  spot  to  the  right  of  the  median 
line.  Diffuse  pain  and  tenderness  is  generally  noted  in 
traumatism,  in  localized  peritonitis  and  perigastritis,  and 


TUMORS   IN   THE   EPIGASTRIUM  33 

in  disturbed  conditions  of  the  solar  plexus  of  the  sympa- 
thetic and  celiac  axis.  Occasionally  the  examiner  finds 
multiple  circumscribed  spots  of  tenderness  over  various 
parts  of  the  epigastrium  or  abdomen,  and  these  are  likely 
to  be  manifestations  of  "nervous  dyspepsia,"  that  will-o- 
the-wisp  of  digestive  disorders. 

Tumors  or  Growths  in  the  Epigastrium.— This  is  a  most 
important  consideration,  for  the  ability  to  rightly  diagnose 
and  weigh  the  significance  of  tumors  in  this  region  cannot 
be  overestimated. 

I  will  enumerate  a  number  of  them,  and  briefly  discuss 
their  possible  bearing  on  disturbances  in  the  epigastric 
locality  or  the  whole  body.  Tumors  of  the  stomach  proper, 
usually  carcinomatous,  rarely  sarcomatous,  or  due  to 
inflammatory  infiltration  and  deposits  around  a  gastric 
ulcer,  may  sometimes  be  felt  here,  especially  when  the 
patient  takes  a  deep  breath,  driving  the  abdominal  viscera 
down  from  out  the  cover  of  the  diaphragmatic  dome. 
As  to  the  pylorus,  it  must  not  be  forgotten  that  the  normal 
pylorus  can  sometimes  be  felt  in  a  child,  or  slender  adult, 
as  a  round,  finger-like  mass  deep  in  the  right  side  of  the 
epigastrium.  The  actual  connection  of  a  gastric  tumor 
with  the  stomach  can  be  proved  more  clearly  if  that  viscus 
is  inflated  with  carbonic  acid  gas,  according  to  directions 
previously  given. 

The  transverse  colon  traverses  the  lower  part  of  the  epi- 
gastrium in  many  cases.  Its  sacculation  and  peristalsis 
can  often  be  made  out  in  rachitic  children  or  thin  adults, 
paticularly  when  they  are  flatulent  or  constipated.  In 
Hirschsprung's  disease,  or  congenital  dilatation  of  the  colon, 
if  there  is  fecal  accumulation,  there  may  be  an  immense 
tumor  squarely  in  the  epigastrium.  In  aged  people  with 
stiffened  and  sclerotic  intestinal  walls,  the  colon  can  fre- 
quently be  plainly  palpated  in  the  epigastrium,  and  its 
sacculated  feeling  may  be  much  like  a  tumor. 

Tumors  in  connection  with  the  omentum  usually  lie 
below  the  colon,  but  in  tubercular  peritonitis  these  inflam- 
3 


34  DIAGNOSTIC   METHODS 

matory  growths  in  their  exuberance  may  extend  well  up 
into  the  epigastrium.  The  same  may  be  said  of  malignant 
nodules. 

I  have  in  mind  at  present  two  instances  of  this  sort,  one 
still  living,  in  which  the  epigastrium  showed  a  crowded 
mass  of  tumors  originating  lower  down  in  the  abdominal 
cavity. 

Swellings  derived  from  the  pancreas  sometimes  extend 
forward  from  the  depths  of  the  abdominal  cavity,  being 
felt  vaguely  in  the  epigastric  and  upper  umbilical  region. 
They  are  sometimes  most  puzzling.  These  tumors  have 
the  stomach  in  front  of  them  and  are  seemingly  fixed  to 
the  posterior  abdominal  wall.  They  move  but  little  on 
respiration,  and  sometimes  require  complete  anesthesia 
for  their  disclosure.  These  tumors  may  be  carcinomatous, 
and  may  leave  in  their  wake  wasting,  anemia,  jaundice 
and  death. 

The  so-called  pancreatic  cysts  are  sometimes  located  here, 
but  are  in  reality  not  pancreatic  but  "peripancreatic 
cysts,"  as  denominated  by  Jex  Blake. 

Tumors  in  connection  with  the  duodenum  may  be  felt 
in  the  right  side  of  the  epigastrium,  and  are  usually  due 
to  primary  malignant  disease.  Many  of  these  are  not 
recognized  on  account  of  the  lack  of  careful  and  deep 
palpation,  for  they  are  deeply  placed,  and  have  to  be  differ- 
entiated from  such  conditions  as  cancer  of  the  stomach, 
pylorus,  pancreas,  bile  ducts,  and  portal  fissure  generally, 
not  by  their  physical  signs  so  much  as  by  the  general 
symptoms  and  progress  of  the  malady.  A  growth  on  the 
first  part  of  the  duodenum  gives  rise  to  symptoms  practi- 
cally like  those  of  cancer  of  the  pylorus — wasting,  anemia, 
dilatation  of  the  stomach  with  visible  and  restless  peris- 
talsis, attacks  of  copious  vomiting,  and  perhaps  occasional 
hematemesis.  Jaundice  will  not  be  present  unless  second- 
ary growths  occur  in  the  portal  fissure.  Malignant  disease 
with  palpable  tumor  in  the  second  part  of  the  duodenum, 
involving  the  bile  ducts,  soon  produces  a  marked  jaundice 


EXAMINATION   OF    THE   ABDOMEN  35 

of  the  obstructive  type.  Cancer  in  the  third  part  of  the 
duodenum  produces  duodenal  stenosis,  dilatation  of  the 
duodenum  and  stomach  and  troublesome  vomiting.  In 
the  last-named  condition,  the  vomitus  will  contain  bile 
and  pancreatic  ferments. 

Growths  in  connection  with  the  kidneys  and  suprarenal 
capsules  occur  in  the  epigastrium  only  after  they  have 
reached  considerable  size.  They  rise  up  out  of  the  loin 
and  flanks,  and  their  diagnosis  at  such  an  advanced  stage 
should  cause  no  confusion. 

Sometimes  enlargement  of  the  spleen  brings  its  blunt 
anterior  end  into  the  epigastrium.  This,  too,  should  be 
obvious  when  it  occurs. 

In  every  region  of  the  abdomen  there  is  a  plentiful  supply 
of  lymphatic  glands,  and  these  glands  are  prone  to  become 
enlarged  and  palpable.  When  such  are  felt  the  physician 
should  be  mindful  of  Hodgkin's  disease,  chronic  peritonitis, 
tuberculous  peritonitis,  or  malignant  growths.  In  the 
epigastrium  the  glands  may  be  felt  as  nodulated  chains  or 
masses,  usually  hard  and  rounded,  but  softer  and  even 
cystic  if  their  contents  caseate  or  break  down  into  pus ;  they 
occasionally  calcify,  becoming  hard  and  stony.  The  en- 
larged glands  appearing  only  on  the  epigastric  region  belong 
to  the  stomach  or  mesentery,  and  the  diagnosis  of  their 
significance  is  always  important. 

EXAMINATION  OF  THE  ABDOMEN  BELOW  THE 
EPIGASTRIUM 

A  careful  examination  of  this  region  is  most  important, 
and  in  many  instances,  enlightening.  In  the  several  divi- 
sions of  this  area  there  is  much  to  be  noted,  much  to  be 
considered.  In  the  preparation  of  the  following,  I  am 
greatly  indebted  to  Dr.  Jex  Blake. 

Left  Hypochondriac  Region. — An  abnormally  lobulated 
liver  may  make  a  superficial  tumor  in  this  area,  but  it  will 
be  continuous  with  the  main  mass  of  that  organ.     A  tumor 


36  DIAGNOSTIC  METHODS 

of  the  left  lobe  of  the  liver  may  also  project  superficially 
into  the  left  hypochondrium. 

A  part  of  the  stomach  lies  normally  in  this  region,  and 
the  presence  of  a  gastric  tumor  may  need  to  be  differentiated 
from  a  splenic  tumor.  This  may  be  done  by  noting  that 
the  stomach,  being  mobile,  changes  position  with  respira- 
tion, while  the  spleen  is  capable  of  but  little  movement. 

The  normal  spleen  is  not  palpable  in  the  abdomen. 
When  it  is  enlarged,  from  the  first  degree  on  up,  it  can  be 
detected  by  placing  the  patient  in  a  recumbent  position 
with  his  abdominal  walls  freely  relaxed.  The  physician, 
standing  on  the  patient's  left  side,  should  palpate  the  left 
hypochondrium  by  hooking  his  fingers  over  the  costal 
margin  about  the  eighth  or  ninth  costal  cartilages.  The 
fingers  are  firmly  tucked  in  during  expiration,  being  relaxed 
during  inspiration.  The  spleen  can  usually  be  recognized 
by  the  fact  that  it  comes  down  under  the  left  costal  margin 
on  inspiration,  has  a  smooth  surface  and  a  notched  upper 
and  inner  margin. 

Tumors  of  the  pancreas  and  retroperitoneal  cysts  some- 
times extend  into  this  region,  and  rarely  tumors  of  the  left 
kidney  or  suprarenal  body. 

Right  Lumbar  Region. — Sometimes  an  abnormally  lobu- 
lated  liver  may  present  a  thin  flange  of  liver  tissue  in 
this  region,  causing  the  physician  to  mistake  it  for  a  movable 
kidney  or  a  dilated  gall-bladder. 

'  The  ascending  colon  can  usually  be  palpated  and  rolled 
under  the  fingers  in  this  region,  and  in  aged  people  it  may 
feel  almost  like  a  rod.  When  filled  with  feces  it  may  pre- 
sent a  doughy  feel,  and  can  be  moulded  by  pressure. 
Where  there  is  obstruction  lower  down,  the  colon  may  be 
distended,  sacculatedj  and  exhibiting  visible  peristalsis. 
This  colon  may  become  thickened  with  inflammatory 
products,  may  become  abscessed,  or,  from  pericolitis, 
perityphlitis,  appendicitis  or  hyperplastic  tuberculosis, 
may  form  a  thickened  and  tender  mass  directly  under  the 
abdominal  wall.     In   acute   conditions   of  this   sort,    the 


EXAMINATION   OF   THE   ABDOMEN  37 

patient  may  be  acutely  ill,  though  if  such  growths  seem  to 
be  assuming  a  chronicity,  malignancy  may  be  suspected. 

Thickening  of  the  ascending  colon,  with  tenderness,  and 
perhaps  mucous  or  blood-streaked  stools,  may  be  encoun- 
tered in  mucous  colitis  and  dysentery.  It  is  also  found  in 
the  later  stages  of  amebic  dysentery. 

The  ascending  colon  may  be  felt  as  a  sausage-shaped 
tumor  in  acute  and  chronic  ileocecal  or  ileocolic  intussus- 
ception. It  may  appear  first  in  the  right  iliac  region, 
extended  across  the  abdomen  at  or  above  the  umbilicus, 
and  then  down  the  left  into  the  pelvis.  Along  with  this 
will  be  spasmodic  abdominal  pain,  vomiting,  passage  of 
mucus  and  blood  by  the  rectum,  and  tenesmus. 

The  small  intestine  is  rarely  the  cause  of  abdominal  tume- 
faction, unless  in  the  case  of  enteric  intussusception. 

Tumors  in  connection  with  the  right  kidney  usually 
make  their  appearance  deep  down  in  this  region,  with  the 
ascending  colon  and  perhaps  the  small  intestine  in  front  of 
them.  The  characteristic  feature  of  such  tumors  is  that 
they  may  be  lifted  forward  en  masse  from  behind  by  a 
hand  placed  at  the  back  of  the  loin.  Furthermore,  the 
peculiar  shape  and  consistency  of  a  movable  kidney,  and 
the  sickening  sensation  elicited  as  it  is  pressed  upon,  should 
be  noted. 

Umbilical  Region. — Since  X-ray  examinations  of  this  re- 
gion after  a  bismuth  test -meal  have  become  so  frequent, 
it  has  been  discovered  that  the  stomach  is  much  more 
movable  than  was  formerly  supposed,  and  that  even  in 
health  its  lower  border  often  extends  below  the  level  of  the 
umbilicus.  If,  however,  very  much  of  the  stomach  is 
found  in  the  umbilical  area,  pathologic  dilatation  or  ptosis 
may  be  inferred. 

Tumors  in  reference  to  the  transverse  colon  have  been 
previously  considered;  likewise  tumors  in  connection  with 
the  omentum. 

Growths  arising  from  the  duodenum,  kidneys,  supra- 
renals,  pancreas,  and  mesentery  may  all  be  encountered 


38  DIAGNOSTIC   METHODS 

in  the  deeper  portions  of  the  umbilical  region,  usually  as 
more  or  less  fixed  masses  arising  from  or  connected  with 
some  definite  part  of  the  posterior  abdominal  wall.  Their 
satisfactory  diagnosis  will  depend  largely  on  the  condition 
of  the  patient,  the  amount  of  adipose  tissue  present,  and 
the  degree  of  relaxation  obtained. 

The  aorta  bifurcates  just  below  and  just  to  the  left  of 
the  umbilicus.  In  thin  and  relaxed  individuals  this  por- 
tion of  the  aorta  is  plain  indeed,  and  its  throbbing  presence 
not  infrequently  excites  suspicion  of  aneurysm.  Aneurysm 
here  is  quite  rare,  and  the  normal  aorta  lacks  that  lateral 
expansion  that  is  found  in  this  abnormality. 

Left  Lumbar  Region.^ — The  most  frequent  tumorous 
"growth  in  this  region  is  an  enlarged  spleen.  Tumors  of 
the  stomach,  omentum,  suprarenal,  kidney  or  descending 
colon  may  be  found  in  this  area,  and  they  can  generally  be 
differentiated  from  splenic  dulness  without  special  difficulty. 

Right  Inguinal  Region  and  Right  Iliac  Fossa. — This  is 
a  region  fraught  with  many  problems,  and  embracing  many 
diagnostic  pitfalls  for  the  unwary.  Swellings  and  growths 
in  the  inguinal  region  rarely  are  confined  to  it,  but  extend 
more  or  less  into  the  right  iliac.  In  this  fossa  may  be 
encountered  inflammatory  thickenings  and  abscesses  con- 
nected with  the  cecum  and  appendix,  bearing  in  connections 
symptoms  such  as  abdominal  pain,  fever,  vomiting  and 
constipation.  The  physical  signs  in  some  of  these  condi- 
tions are  deceptive,  and  not  at  all  commensurate  with  their 
gravity.  Sarcoma  or  lymphosarcoma  of  the  cecum  is 
quite  rare,  and  gives  rise  to  a  softer  mass  and  more  rapid 
growth  than  a  cecal  carcinoma. 

The  diagnosis  of  appendicitis  is  given  in  full  elsewhere  in 
this  book. 

Inflammation  of  the  right  ovary  or  tube,  or  ovarian 
neuralgia,  may  produce  symptoms,  especially  in  nervous 
patients,  closely  simulating  appendicitis.  A  doubt  under 
such  circumstances  may  be  cleared  up  by  a  vaginal 
examination. 


EXAMINATION   OF    THE   ABDOMEN  39 

Inflammatory  swellings  and  abscesses  in  the  left  iliac 
fossa  may  arise  in  connection  with  psoas  abscess,  from  the 
swelling  or  breaking  down  of  lymphatic  glands,  infected 
from  perhaps  some  small  wound  in  the  leg  or  perineum. 

Left  Inguinal  Region  and  Left  Inguinal  Fossa. — The  sig- 
moid flexure  is  here,  and  when  filled  with  scybalous  masses 
forms  quite  a  prominent  swelling.  This  region  is  sometimes 
the  seat  of  cancerous  growth,  accompanied  by  cachexia, 
the  passage  of  blood-stained  stools,  and  followed  later  by 
intestinal  obstruction. 

Before  leaving  this  subject  it  will  be  well  to  discuss  the 
so-called  "Head  zones,"  which  have  received  considerable 
attention  in  some  quarters.  According  to  Dr.  Head, 
stimulation  is  excited  from  diseased  states  of  internal 
organs,  and,  being  transmitted  by  way  of  the  sympathetics 
to  a  distinct  spinal  segment,  are  referred  to  sensory  fibers 
of  the  skin  which  pass  backward  into  the  same  segment. 
This  means  the  existence  of  hyperalgesic  areas  on  the  body 
reflexly  caused  by  disease  of  organs  within,  and,  according 
to  the  localities  on  the  skin  in  which  these  areas  are  observed, 
inferences  of  diagnostic  worth  should  be  assumed  as  to 
which  of  the  internal  organs  are  affected  and  where  the 
lesion  is  situated. 

These  zones  have  some  value,  when  taken  in  connection 
with  other  symptoms,  but  too  much  weight  must  not  be 
accorded  them  alone.  Where  certain  sensitive  spots  are 
due  to  hysteria,  uremia,  neuralgia,  or  central  nervous 
diseases,  to  separate  them  from  the  "Head  zones"  is  an 
impossible  task.  Bassler  admits  that  the  pyloric  and  gall- 
bladder zones  are  more  often  present  than  the  others,  but 
even  to  these  too  much  diagnostic  significance  should  not 
be  given. 

There  are  certain  gastric  conditions,  however,  in  which 
pressure  spots  of  real  diagnostic  worth  have  been  located. 
Boas  has  shown  that  in  gastric  ulcer,  about  one-third  of  the 
cases  give  tender  pressure  points  situated  to  the  left  of  the 
spine  close  to  the  twelfth  dorsal  vertebra.     In  my  experi- 


40  DIAGNOSTIC   METHODS 

ence,  and  that  of  some  other  American  observers,  this  spot 
is  generally  higher  up,  being  at  or  near  the  tenth  dorsal 
vertebra.  When  present,  this  spot  is  noted  as  a  very  tender 
area  close  to  the  spinous  process  and  keenly  painful  to 
deep  point  pressure.  Some  cases  are  seen  where  the  char- 
acteristic tender  spot  is  to  the  right  of  the  spine,  being 
suggestive  of  ulcer  of  the  pylorus  or  duodenum.  Kell- 
ing  explains  these  spots  as  being  due  to  the  supersensitive 
posterior  branch  of  the  intercostal  nerves,  which  in  turn  are 
due  to  a  reflex  hyperesthesia  from  the  sympathetic  nerves. 

The  physician,  in  searching  for  these  tender  spots,  must 
riot  be  misled  by  other  tender  spots  (usually  higher  up)  due 
to  neurasthenia,  disease  of  the  spine  or  cord,  or  infectious 
disease. 

Any  tender  spots  in  the  back  that  cover  a  rather  large 
area,  are  perhaps  on  both  sides  of  the  spine,  and  range  up, 
are  probably  the  expression  of  a  neurosis.  These  neurotic 
tender  spots  are  inclined  to  shift  from  place  to  place,  and 
do  not  manifest  that  extreme  tenderness  in  one  small  spot 
as  do  the  tender  areas  from  gastric  ulcer. 

In  gall-bladder  disease  there  is  generally  found  a  painful 
area  in  the  back  on  the  right  side.  This  area  is  diffuse, 
though  in  simple,  uncomplicated  gall-stone  disease  it  may 
be  located  in  a  rather  small  area  to  the  right  of  the  eleventh 
dorsal  vertebra  and  along  the  course  of  the  last  ribs.  In 
cholelithiasis  a  reflex  area  of  tenderness  may  be  found  in 
the  back  of  the  right  shoulder  at  the  upper  part  of  the  scap- 
ula. This  is  so  common  that  it  has  been  noted  by  the  laity, 
and  referred  to  by  them  as  a  "liver  pain."  In  disease  of 
the  intestines,  especially  where  the  colon  is  crowded  with 
feces,  there  is  often  present  a  transverse  dragging  pain  in 
the  back.  In  enlargements  of  the  spleen  (malaria,  leuke- 
mia) the  dragging  weight  of  this  organ,  or  the  tension  of  its 
fibro-elastic  framework  brought  about  by  rapid  swelling, 
may  cause  a  somewhat  acute  pain  midway  between  the 
spine  and  thoracic  margin  about  the  eighth  rib. 

A  general  caution  may  be  inserted  in  connection  with 


TRANSILLUMINATION   OF   STOMACH  4 1 

the  search  for  tender  spots  on  the  abdomen  or  back: 
Many  patients,  who  come  to  the  physician  for  diagnosis  of 
digestive  diseases,  are  neurotic  in  the  extreme,  and  have 
preconceived  ideas  as  to  their  malady.  These  ideas  nat- 
urally color  their  statements,  and  cause  them  to  magnify 
the  soreness  of  certain  areas,  while  they  may  minimize 
that  of  other  areas,  perhaps  more  important.  In  such 
cases  the  examiner  should  be  on  his  guard,  not  letting  the 
patient  know  that  he  expects  to  find,  nor  bringing  out 
answers  by  leading  questions.  I  have  in  more  than  one 
instance,  by  suggestive  inquiries  purposely  given,  elicited 
a  history  totally  at  variance  with  the  real  pathologic  condi- 
tion. I  find  it  useful  at  times  to  direct  my  questions 
negatively,  and  if  there  is  no  affirmation  of  the  symptoms 
sought,  it  may  be  considered  fairly  certain  that  they  do  not 
exist.  For  instance,  in  pellagra,  I  would  not  ask,  "Do  you 
have  shooting  pains  in  the  limbs?"  but  ask  instead  the 
question  "You  have  never  been  troubled  with  shooting 
pains,  have  you?"  Some  phlegmatic  and  matter-of-fact 
individuals  are  inclined  to  minimize  all  their  symptoms, 
and  the  physician  must  in  such  cases,  allow  an  added  weight 
to  the  somewhat  grudging  admission  of  illness.  These 
are  the  toilers  of  both  sexes,  who  feel  that  they  have  no 
time  for  sickness,  and  who,  only  by  careful  questioning, 
will  grant  the  examiner  a  full  and  comprehensive  history  of 
subjective  symptoms. 

TRANSILLUMINATION  OF  THE  STOMACH  OR 
GASTRODIAPHANY 

Viewing  the  shape  of  the  stomach  from  outside  the  body 
by  means  of  brightly  illuminating  the  inside  of  this  organ 
has  a  limited  use  in  diagnosis.  By  the  employment  of 
transillumination  of  the  stomach,  gastroptosis,  dilatation, 
irregularities  in  contour,  and  occasionally,  morbid  growths 
may  be  recognized. 

Casenave,  in  1845,  first  applied  this  method  to  living 
tissues,  and  in  1867  Milliot  experimented  quite  extensively 


42  DIAGNOSTIC  METHODS 

with  it  in  the  stomachs  of  animals  and  cadavers.  To  Dr. 
Max  Einhorn,  however,  we  owe  its  availabiUty  in  trans- 
illuminating  the  stomachs  of  living  humans,  and  demon- 
strating its  worth. 

Einhorn 's  instrument  consists  of  a  soft -rubber  and  rather 
small  stomach-tube,  through  which  runs  a  small  cable, 
carrying  at  the  distal  end  a  little  Edison  lamp.  The  other 
end  of  the  wires  are.  connected  with  a  battery,  and  there 
is  a  convenient  interrupter  some  distance  from  the  tube. 
The  lamp  is  enclosed  in  a  small  glass  bulb,  which  both  acts 
as  a  reflector  and  prevents  the  heat  of  the  light  from  burning 
the  stomach  mucosa.  He  has  the  patient  drink  about  two 
glasses  of  water,  inserts  the  light,  and  examines  him  in  a 
darkened  room. 

As  it  was  difficult  to  move  or  adjust  the  lamp  in  the  stom- 
ach with  any  degree  of  certainty,  Kemp  devised  a  circum- 
scribing gastrodiaphane,  in  which  there  was  used  a  cable 
about  6  inches  longer  than  the  Einhorn  instrument,  but 
about  the  same  caliber.  The  cable  is  more  flexible  in  the 
vicinity  of  the  light,  allowing  rather  free  movement.  At 
the  base  of  the  light  is  attached  an  extremely  thin  accessory 
cable,  running  parallel  with  the  main  cable,  and  increasing 
its  size  but  little.  After  introducing  the  light  as  far  as  is 
desired,  the  accessory  cable  is  gently  drawn  upon,  and  by 
slightly  shifting  the  angle  of  the  main  cable,  the  light  can 
be  moved  almost  at  will  in  the  stomach.  A  little  practice 
and  care  will  enable  the  physician  to  get  a  fairly  accurate 
idea  of  the  stomach  contour  in  this  manner.  Care  should 
be  taken  that  the  two  cables  are  parallel  when  passed  into 
the  stomach,  and  that  the  accessory  cable  is  sufficiently 
relaxed  before  the  two  are  withdrawn.  Eight  dry  cells 
with  a  rheostat  will  afford  ample  strength,  and  this  may  be 
procured  in  the  form  of  a  pocket  battery.  It  is  advisable 
to  have  an  extra  lamp  at  hand  in  case  of  need. 

Water  was  the  medium  formerly  employed,  but  a  great 
advance  has  been  achieved  in  the  use  of  fluorescent  media. 
Three  such  media  have  been  found  to  be  of  value. 


TRANSILLUMINATION   OF    STOMACH  43 

Bisulphate  of  quinin,  lo  grains  to  a  pint  of  water,  to- 
which  may  be  added  five  drops  of  dilute  phosphoric  acid. 
The  reaction  of  this  solution  is  acid,  and  the  fluorescence 
a  pale  violet.  This  fluorescence  is  somewhat  increased  by 
greater  acidity,  but  disappears  if  the  solution  becomes 
alkaline. 

Esculin. — This  is  a  preparation  obtained  from  the 
^sculus  hippocastanum  (horse-chestnut)  indigenous  to 
Europe.  An  eighth  to  half  a  grain  of  esculin  in  half  a 
pint  of  an  alkaline  solution  will  give  a  pale  blue 
fluorescence. 

Fluorescin  (phthalic  anhydrid,  five  parts) ,  a  naphthalin 
product,  and  resorcin  (seven  parts),  heated  to  200°  C. 
This  is  a  reddish  powder,  slightly  soluble  in  water,  neutral 
in  reaction,  but  not  fluorescent  in  this  reaction.  In  an 
alkaline  medium  it  gives  a  beautiful  green  fluorescence,  a 
liquid  opal. 

The  last  is  the  most  available  agent  for  this  purpose,  and 
may  be  obtained  from  Merck  &  Co.  quite  cheaply.  The 
addition  of  a  small  quantity  of  glycerin  adds  to  the  fluor- 
escence, and  the  contents  of  the  stomach  must  be  alkalin- 
ized.  There  should  be  given  first  two  or  more  glasses  of 
water  in  which  about  half  a  dram  of  soda  has  been  dis- 
solved; this  should  be  followed  by  another  glass  of  water, 
in  which  are  dissolved  a  dram  of  glycerin  and  half  a  grain  of 
fluorescin. 

This  method  greatly  enhances  the  value  of  transillumina- 
tion, and  the  fluorescin  exerts  no  deleterious  effects.  On 
catheterization  of  these  patients,  greenish  fluorescent  urine 
is  obtained  an  hour  after  the  administration  of  the  above- 
mentioned  solution,  but  no  albumen,  sugar  nor  casts  have 
been  found. 

In  order  to  obtain  satisfactory  results  from  gastrodi- 
aphany,  the  patient  should  be  in  a  dark  room,  with  the 
abdomen  and  back  exposed  to  view.  The  lamp  and  tube 
may  be  introduced  by  artificial  light,  which  is  put  out 
before  the  internal  lamp  is  lit.     When  the  electric  current 


44  DIAGNOSTIC  METHODS 

is  turned  on,  the  patient  should  stand  up,  for  in  this  position 
every  outHne  of  the  stomach  is  more  plainly  visible. 

With  gastroptosis,  the  lesser  curvature  can  be  outlined, 
while  with  a  dilated  stomach  the  complete  contour  can 
often  be  observed. 

If  we  illuminate  in  the  dorsal  position,  but  little  will  be 
shown,  for  as  Meltzing  contends,  there  is  but  little  of  the 
stomach  against  the  anterior  wall  of  the  abdomen  in  this 
position. 

CHEMIC  EXAMINATION  OF  THE  STOMACH 
CONTENTS 

The  examination  of  the  stomach  contents  after  the 
ingestion  of  different  test -meals  is  now  recognized  almost 
universally  as  a  diagnostic  method  of  great  worth.  Suit- 
able allowance  should  be  made  for  modifying  factors,  and 
the  clinical  history  of  the  case  should  not  be  disregarded, 
but  it  is  admitted  by  all  unprejudiced  observers  that  certain 
conclusions  may  be  formed  from  the  chemic  examination  of 
test-meals  that  cannot  be  reached  any  other  way. 

It  has  been  demonstrated  by  physiologists  that  the  secre- 
tions of  the  stomach  begin  as  soon  as  the  food  enters  that 
viscus,  continuing  until  the  chyme  has  passed  into  the 
intestiries,  though  with  lesser  activity  toward  the  end  of 
stomach  digestion.  It  follows,  therefore,  that  examinations 
at  different  periods  of  digestion  will  give  different  results, 
and  it  is  best  to  make  the  examination  at  a  definite  time  and 
during  the  height  of  digestion.  For  this  purpose  a  number 
of  test-meals  have  been  devised,  which,  being  extracted  at 
different  times  after  ingestion,  naturally  give  different 
results. 

TEST-MEALS 

Riegel's  Test-dinner. — This  is  the  oldest  one  used,  and 
consists  of  a  plate  of  meat  broth  weighing  from  5  to  7 
ounces,  i  1/2  ounces  of  mashed  potatoes,  and  a  plain,  roll. 


TEST-MEALS  45 

This  should  be  extracted  from  the  stomach  four  hours  after 
eating. 

Ewald's.^ — -This  is  another  of  the  early  test-meals.  It 
consists  of  6  ounces  of  finely  chopped  meat,  stale  bread  i 
ounce,  and  a  little  butter.  This  should  be  extracted  in 
three  hours. 

Germain-See's  Test-meal. — In  this  test-meal  the  patient 
is  given  3  to  5  ounces  of  white  bread,  2  or  3  ounces  of  finely 
chopped  meat,  and  a  large  glass  of  water.  This  is  to  be 
extracted  in  two  hours. 

Ewald-Boas  Test-meal. — This  is  the  most  available  one, 
and  for  plain  examination  of  the  chemic  functions  of  the 
stomach,  is  probably  used  more  than  any  other.  It  con- 
sists of  two  slices  of  white  bread,  toasted  if  preferred  (no 
butter),  and  a  glass  and  a  half  of  water.  This  should  be 
extracted  in  exactly  one  hour. 

Boas  has  suggested  a  dry  test-meal,  consisting  of  a  plain 
roll  without  any  water,  but  this  is  difficult  to  take,  and 
possesses  no  commensurate  advantages. 

Boas'  Test-breakfast. — One  ounce  of  rolled  oats  boiled 
in  I  pint  of  water.  This  is  indicated  where  an  accurate 
test  for  lactic  acid  is  desired,  as  it  contains  none  of  this 
acid. 

In  the  employment  of  test-meals,  there  are  several  modi- 
fying factors,  both  physical  and  psychic,  to  be  considered. 
The  meal  should  be  an  indication  of  what  the  stomach  is 
doing  and  its  condition  at  the  time  the  test-meal  is  extracted. 
To  place  the  patient  under  the  influence  of  adverse  cir- 
cumstances, such  as  change  of  habits  or  fear,  defeats  the 
object  in  view.  So  far  as  practicable,  it  is  not  wise  to 
inform  the  patient  that  the  stomach  is  to  be  aspirated  at 
the  next  visit,  and,  if  he  asks  the  direct  question,  the  phy- 
sician, while  not  deceiving  him,  should  do  all  that  is  possible 
to  allay  his  fears.  It  is  my  custom,  when  I  desire  a  patient 
to  return  for  a  test-meal,  to  simply  inform  him  that  I  wish 
him  to  come  for  "further  examination." 

It  is  best  that  a  test-meal  should  be  taken  in  the  morning 


46  DIAGNOSTIC   METHODS 

on  an  empty  stomach,  or  at  least  where  nothing  but  water 
has  been  ingested  one  or  more  hours  previously.  This  is 
not  always  practicable,  and  variations  from  this  particular 
time  have  to  be  resorted  to.  Any  time  up  to  noon  the  pa- 
tient may  be  required  to  abstain  from  food  until  the  test- 
meal  is  taken;  later  than  that,  however,  it  is  well  to  permit 
a  light  repast  that  will  pass  out  of  the  stomach  before  the 
test-meal  is  taken.  I  often  take  test-meals  at  one,  two 
or  three  in  the  afternoon,  when  the  early  morning  hour  is 
not  practicable. 

There  are  many  circumstances  and  conditions  in  private 
practice  quite  different  from  hospital  practice,  and  the 
resourceful  physician  must  meet  these  differences  with  tact 
and  intelligence. 

Some  observers,  mostly  European,  use  tea  as  the  fluid  of 
test-meals.  In  my  opinion  water  is  preferable,  as  tea 
irritates  some  stomachs,  and  besides  has  no  uniform 
strength. 

The  methods  of  extracting  test-meals,  and  other  consid- 
erations involved  therein,  are  fully  discussed  in  a  separate 
chapter. 

Before  chemically  testing  the  ingesta,  several  points  may 
be  brought  out  by  a  microscopic  examination.  Some 
gastroenterologists  advise  a  careful  measurement  of  the 
aspirated  contents,  but,  as  I  do  not  think  it  necessary  to 
entirely  empty  the  stomach,  except  for  special  reasons,  I 
do  not  follow  this  procedure.  If,  however,  a  very  large 
quantity  is  easily  aspirated  several  hours  after  a  test-meal, 
it  would  excite  suspicion  of  hypersecretion,  and  a  test  of 
both  the  secretory  and  motor  functions  would  be  in 
order. 

Microscopic  inspection  may  disclose  large  undigested 
pieces  of  bread ;  in  others  remnants  of  bread  that  are  nearly 
digested  or  slightly  digested;  in  others  a  fine  fluid  mushy 
mass.  These  findings  are  at  once  suggestive.  After  a 
Riegel's  test-meal  the  differences  are  more  distinctive;  for 
the  mass  may  be  fine,  uniform  and  mushy,  containing  no 


EXAMINATION   OF    STOMACH   CONTENTS  47 

coarse  elements;  or  there  may  be  coarse  undigested  meat 
fibers. 

Mucus,  frank  blood  or  plentiful  bile  are  readily  visible. 
In  some  instances  the  gastric  contents,  when  placed  in  a 
glass  vessel,  form  three  layers :  at  the  bottom,  a  fine  starchy, 
fluffy  mass;  next  a  cloudy  zone;  and  on  top  a  foamy  layer, 
the  last-named  being  evidence  of  gaseous  fermentation. 

In  cases  of  achylia  gastrica,  especially  in  senile  cases,  the 
bread  is  aspirated  with  difficulty,  and  presents  a  dry  and 
unchanged  appearance.  The  unresponsive  and  almost 
parched  gastric  mucosa  of  these  aged  patients  absorbs  the 
fluid  of  the  test-meal,  instead  of  secreting  any  juice  of  its 
own. 

The  gross  amount  of  mucus  present  may  be  tested  by 
a  hooked  wire,  which  is  passed  through  the  contents  and 
drawn  up.  In  excessive  amounts  of  mucus,  there  are  long 
strings  visible,  varying  in  viscosity.  This  mucus  may  be 
clear  or  stained  with  the  pathologic  coloring  matter  in  the 
stomach.  In  rare  instances  blood-stained  mucus  may  be 
picked  up  on  this  wire. 

Odor. — In  normal  test-meals  the  odor  is  "bready"  and 
not  disagreeable.  In  some  pathologic  conditions  the  odor 
is  anything  but  pleasant,  varying  from  a  "fermenting  smell" 
to  a  distinct  putrescence.  In  the  presence  of  advanced 
carcinoma,  with  decided  obstruction,  the  odor  may  be  foul 
indeed. 

Before  beginning  the  chemic  examination  proper,  the 
contents  should  be  filtered.  The  regular  filter  paper  is 
preferable,  though,  if  this  cannot  be  obtained,  several  layers 
of  gauze  or  cheese-cloth  will  answer. 

For  practical  purposes  the  most  important  feature  to 
determine  is  the  amount  of  hydrochloric  acid  present,  free 
or  combined,  during  the  height  of  digestion.  Should 
hydrochloric  acid  be  present,  it  is  necessary  to  ascertain 
whether  it  is  normal  in  quantity,  increased  or  deficient. 
Should  it  either  be  absent,  or  deficient  in  amount,  then 
lowered  digestive  power  of  the  stomach  is  proved. 


48  DIAGNOSTIC  METHODS 

When  free  hydrochloric  acid  is  present  in  easily  appreci- 
able amount,  the  determination  of  pepsin  is  unnecessary; 
in  fact,  pepsin  may  be  present  when  the  acid  is  absent; 
but  the  presence  of  hydrochloric  acid  is  prima  facie  evidence 
of  the  presence  of  pepsin.  In  the  total  absence  of  the  acid, 
tests  for  pepsin  should  be  employed. 

For  a  complete  chemic  examination  and  analysis  the 
following  tests  should  be  carried  out : 

1.  Reaction. 

2.  Free  hydrochloric  acid. 

3.  Total  acidity. 

4.  Combined  hydrochloric  acid. 

5.  Organic  acids  (lactic,  acetic,  butyric). 

6.  Propepton. 

7.  Pepton. 

8.  Pepsin. 

9.  Renin. 

10.  Dextrin. 

11.  Erythrodextrin. 

12.  Achroodextrin. 

13.  Occult  blood. 

14.  Bile  and  intestinal  juices. 

Before  judging  of  abnormal  conditions  in  test-meal  find- 
ings, it  is  necessary  that  the  examiner  should  be  familiar 
with  normal  conditions. 

A  normal  Ewald-Boas  test-meal,  extracted  an  hour  after 
ingestion,  should  show  free  hydrochloric  acid,  15  to  25; 
total  acidity,  50  to  60 ;  propepton  and  pepton,  small  amount ; 
pepsin  and  rennin  present;  erythrodextrin  present  in  small 
amount,  or  absent;  dextrin  absent. 

Some  patients  may  have  the  free  hydrochloric  acid  pres- 
ent within  normal  limits,  and  suffer  with  symptoms  of  hyper- 
acidity; others  may  have  a  marked  excess  of  free  acid,  and 
complain  of  no  special  discomfort  pointing  to  that  con- 
dition. This  is  to  a  great  extent  a  matter  of  individual 
peculiarity. 


EXAMINATION   OF    STOMACH   CONTENTS  49 

Reaction. — This  may  be  determined  by  blue  and  red 
litmus  paper.  Should  the  filtrate  be  acid,  it  turns  the  blue 
paper  red;  and  conversely,  if  it  is  alkaline,  it  turns  the  red 
paper  blue.  In  a  filtrate  of  neutral  reaction,  there  is,  of 
course,  no  change. 

For  a  qualitative  estimate  of  the  presence  of  acid  in 
general,  and  free  hydrochloric  acid  in  particular,  congo-red 
and  dimethylamidoazobenzol  paper  may  be  used  (the 
latter  is  usually  called  dimethyl  paper).  The  presence  of 
any  acid  turns  the  congo-red  paper  blue;  and  the  deepness 
of  the  blue  is  to  an  extent  an  indicator  of  the  amount  of 
free  acid  in  the  filtrate.  The  dimethyl  paper  responds  to 
hydrochloric  acid,  and  turns  red  in  its  presence.  A  small 
amount  of  free  hydrochloric  acid  may  turn  the  yellow  di- 
methyl paper  only  a  light  pink,,  while  a  great  amount  will 
turn  it  a  bright  scarlet.  While  this  method  is  by  no  means 
exact,  a  fairly  good  estimate  may  be  made  by  it,  which 
will  give  the  doctor  a  "working  basis"  until  a  quantitative 
estimate  can  be  made. 

Tests  for  Free  Hydrochloric  Acid. — Many  tests  for  this 
acid  have  been  advocated,  some  of  which  possess  but  little 
merit.  Most  of  these  tests  are  based  upon  the  assumption 
that  certain  coloring  matters  respond  to  mineral  acids  and 
not  to  organic.  About  the  only  organic  acid  liable  to  inter- 
fere is  the  lactic,  and  this  can  be  eliminated,  if  necessary, 
by  quantitative  check  tests. 

Gunsburg's  Phloroglucin-vanillin  Test. — This  reagent 
consists  of  2  grams  of  phloroglucin  and  i  gram  of  vanillin 
dissolved  in  30  grams  of  absolute  alcohol.  Into  a  small 
porcelain  dish  are  placed  an  equal  number  of  drops  of  this 
reagent  and  gastric  filtrate.  The  disK  is  then  held  over  an 
alcohol  lamp  (not  too  closely)  and  the  contents  allowed  to 
evaporate  slowly.  A  cherry-red  color  appears  if  free  hydro- 
chloric acid  be  present.  If  there  are  only  traces,  a  rose  tint 
appears  at  the  margin;  while  if  no  free  hydrochloric  acid 
is  present,  the  color  of  the  evaporating  solution  varies 
from  a  yellow  to  a  brown. 
4 


50  DIAGNOSTIC   METHODS 

This  test  responds  only  to  free  hydrochloric  acid,  and  not 
to  organic  acids.  The  disadvantage  of  this  method  lies 
in  the  instability  of  the  solution,  which  must  be  made 
fresh  at  frequent  intervals  and  kept  in  a  dark  place. 

Boas'  Resorcin-sugar  Test. — Five  grams  of  resorcin  and 
3  grams  of  cane-sugar  are  dissolved  in  loo  c.c.  of  alcohol. 
An  equal  amount  of  this  reagent  and  gastric  filtrate  are 
slowly  evaporated  to  dryness  in  a  porcelain  dish,  as  in  the 
previous  test.  The  presence  of  free  hydrochloric  acid  is 
demonstrated  by  a  rose-red  color,  which  fades  on  cooling. 
This  responds  to  hydrochloric  acid  only,  and  is  preferable 
to  the  Gunsberg  test.  This  solution  is  both  cheaper  and 
more  stable. 

Toepfer's  Quantitative  Method. — By  this  method  free 
hydrochloric  acid,  combined  hydrochloric  acid,  total  hydro- 
chloric acid,  and  acid  salts  are  readily  and  accurately 
determined.  Ordinary  routine  examinations  seldom  call 
for  more  than  a  determination  of  total  acidity,  free  and 
combined  hydrochloric  acid,  but  when  free  acid  is  absent, 
the  pepsin  and  rennin  tests  may  be  indicated. 

In  the  employment  of  Toepfer's  method  the  following 
solutions  are  required: 

(i)  A  I  per  cent,  alcoholic  solution  of  phenolphthalein 
(colorless) . 

(2)  A  I  per  cent,  aqueous  solution  of  sodium  alizarin 
sulphonate  (brownish  yellow). 

(3)  A  0.5  per  cent,  alcoholic  solution  of  dimethyl- 
amidoazobenzol  (yellowish  red). 

(4)  A  decinormal  solution  of  NaOH  (sodium  hydrate)  as 
a  titrating  solution. 

The  rationale  of  Toepfer's  method  consists  in  the  sensi- 
tiveness of  the  three-color  end-reagents  to  the  various  con- 
stituents of  the  gastric  juice.  To  judge  of  the  different 
stages  of  color  changes  calls  for  a  definite  "color  sense" 
on  the  part  of  the  physician,  and  an  inability  to  note  the 
fine  gradations  of  color,  as  they  blend  one  into  another,  will 


EXAMINATION   OF    STOMACH   CONTENTS  5 1 

seriously  handicap  the  examiner.  I  have  known  several 
otherwise  excellent  diagnosticians,  who,  because  of  their 
indifferent  color  perception,  could  not  successfully  avail 
themselves  of  this  method. 

The  decinormal  solution  should  be  of  such  accurate 
strength  that  i  c.c.  will  neutralize  0.00365  hydrochlgric 
acid. 

Some  use  10  c.c.  of  the  gastric  filtrate  for  each  test,  but 
often  there  is  not  a  great  amount  of  this  filtrate  avail- 
able, and  I  seldom  use  more  than  5  c.c,  but  with  equal  ac- 
curacy. 

Into  each  of  three  beakers  or  small  glass  containers,  are 
put  5  c.c.  of  the  gastric  filtrate.  To  obtain  the  free  hydro- 
chloric acid  two  drops  of  the  solution  of  dimethylamidoazo- 
benzol  are  added,  and  into  this  is  titrated  drop  by  drop  the 
decinormal  solution  of  sodium  hydrate  until  the  filtrate 
turns  an  orange  yellow. 

Some  examiners  make  the  error  of  carrying  this  reaction 
to  a  lemon  yellow,  which  is  incorrect.  To  carry  the  titra- 
tion thus  far  would  put  an  unduly  large  number  into  the 
class  of  hyperchlorhydria.  Let  me  insist  that  the  titration 
be  stopped  at  an  orange  yellow. 

To  obtain  the  total  acidity,  two  drops  of  the  phenol- 
phthalein  solution  are  put  into  another  beaker,  and  the 
decinormal  solution  titrated  into  it  until  the  end-reaction 
of  red  is  reached,  or  until  no  more  redness  is  produced  by 
titration. 

Where  the  gastric  filtrate  is  scanty,  another  convenient 
method  may  be  employed  for  determining  the  total  acidity. 
After  the  free  hydrochloric  acid  has  been  determined,  into 
the  same  solution  may  be  placed  two  drops  of  the  phenol- 
phthalein  solution.  This  produces  no  change  in  color  until 
the  titration  is  proceeded  with,  but  the  end  reaction  of  red 
takes  place  just  the  same  as  in  the  plain  filtrate,  minus  the 
dimethylamidoazobenzol.  Let  the  titration  proceed  until 
the  end  reaction  is  reached,  and  the  sum  of  the  free  hydro- 
chloric   acid,    plus    the    amount    of    decinormal    solution 


52  DIAGNOSTIC   METHODS 

required  to  obtain  the  end  reaction,  will  represent  the  total 
acidity. 

To  obtain  the  combined  acid,  add  to  the  other  beaker  of 
gastric  filtrate  one  small  drop  of  the  sodium-alizarin- 
sulphonate  solution.  Titrate  with  the  decinormal  solution 
until  an  end  reaction  of  a  marked  purple  is  reached. 

The  titration  may  be  performed  with  a  graduated  pipet, 
or,  much  preferably,  a  graduated  buret  supported  on  a 
stand.     This  pipet  or  buret  should  be  graduated  to  1/5  e.c. 

To  obtain  the  combined  acid,  subtract  the  index  of  the 
end  reaction  from  the  total  acidity. 

In  making  these  calculations,  as  the  degree  of  acidity  is 
represented  by  the  number  of  cubic  centimeters  of  the  deci- 
normal solution  required  to  bring  about  the  proper  color 
reaction  in  the  gastric  filtrate,  plus  the  proper  indicating 
solution,  and  the  figures  are  based  on  the  assumption  that 
100  c.c.  of  the  filtrate  will  be  used,  while  in  reality  only 
5  c.c.  are  used,  the  number  of  cubic  centimeters  of  the  deci- 
normal solution  must  be  multiplied  by  20.  For  instance, 
if  I  c.c.  of  the  decinormal  solution  were  required  to  color  the 
gastric  filtrate  plus  the  dimethylamidoazobenzol  solution 
an  orange  yellow,  the  result  should  read  20;  and  that  would 
be  within  normal  limits. 

To  compute  the  free  hydrochloric  acid  in  percentage, 
multiply  the  first  result  by  20,  and  then  by  0.00365. 

If  10  c.c.  of  gastric  juice  are  employed,  multiply  the  result 
by  ID.  Sometimes  where  the  amount  of  the  test-meal  is 
extremely  scanty  as  much  as  5  c.c.  are  not  available  for  the 
tests.  Should  only  2  c.c.  be  available,  the  result  should  be 
multiplied  by  50.  When  as  small  an  amount  as  this  is 
examined,  however,  great  care  should  be  exercised  in  noting 
the  color  gradations,  lest  a  decided  error  ensue  in  the  final 
calculations. 

A  further  suggestion  in  making  these  examinations  is 
to  have  beneath  the  glass  beaker  a  white  ground,  that  a 
good,  clear  light  be  available,  and  that  the  examiner 
should  not  permit  the  possible  reflection  of  colored  walls, 


EXAMINATION    OF    STOMACH   CONTENTS  53 

curtains,    etc.,    to    interfere    with    his  judgment    of  color 
changes,  or  end  reactions. 

Lactic  Acid. — The  most-used  test  is  Uffelmann's,  and 
is  fairly  accurate.  It  should  be  freshly  made  before  each 
test,  and  is  prepared  as  follows:  lo  c.c.  of  a  4  per  cent, 
carbolic  acid  solution  is  mixed  with  20  c.c.  of  distilled  (or 
plain)  water,  and  to  this  is  added  one  drop  of  sesquichlorid 
of  iron.  This  makes  an  amethyst-blue  solution.  Should 
the  blue  be  too  marked,  it  can  be  lightened  by  the  addition 
of  a  small  amount  of  water.  To  this  solution  add  a  few 
drops  of  the  gastric  filtrate,  and,  in  the  presence  of  lactic 
acid,  a  canary-yellow  reaction  follows.  Some  have  de- 
scribed it  as  a  "canary-green,"  but  this  does  not  accord 
with  my  observation.  Fatty  acids  produce  an  ash-gray 
reaction,  and  inorganic  acids  decolorize  the  amethyst -blue 
solution. 

Should  phosphates  be  present,  they  may  give  the  same 
reaction  as  lactic  acid,  and  the  following  modified  Uffel- 
mann  test  has  been  proposed  to  eliminate  that  possible 
error.  Take  5  c.c.  of  the  filtrate  plus  10  c.c.  of  ether,  shake 
it  in  a  test-tube,  and  allow  it  to  stand  until  the  ethereal 
solution  has  separated  from  the  watery  solution.  Pour 
the  ethereal  part  into  another  test-tube,  and  place  it  in  a 
glass  of  hot  water  to  evaporate.  Add  i  c.c.  of  distilled 
water  to  the  remaining  drops,  and  test  for  lactic  acid  with 
the  Uffelmann  solution.  If  the  canary  color  occurs,  lactic 
acid  may  be  considered  present  beyond  a  peradventure. 

Boas'  Test  for  Lactic  Acid. — Take  10  to  20  c.c.  of  the  gas- 
tric filtrate,  and  evaporate  it  into  a  syrupy  consistency  over 
the  water  bath.  Should  free  hydrochloric  acid  be  present, 
neutralize  it  with  an  excess  of  barium  carbonate.  A  few 
drops  of  phosphoric  acid  are  then  mixed  in  and  the  carbonic 
acid  expelled  by  boiling.  The  fluid  is  then  cooled,  and  ex- 
tracted two  or  three  times  with  50  c.c.  of  ether. 

After  half , an  hour  pour  off  the  clear  ethereal  layer.  The 
ether  is  now  evaporated,  and  the  residue  washed  in  a  flask 
with  45  c.c.  of  water,  well  shaken  and  filtered.     Concen- 


54  DIAGNOSTIC   METHODS 

trated  sulphuric  acid,  5  c.c,  and  a  pinch  of  manganese 
dioxid  are  added  to  the  filtrate.  The  mixture  is  then  dis- 
tilled over  a  small  flame,  and  the  vapor  conducted  into  a 
narrow  cylinder  containing  about  10  c.c.  of  an  alkaline  iodin 
solution.  This  consists  of  equal  parts  of  a  decinormal  iodin 
solution  and  the  standard  potassium  hydroxid  solution. 
The  vapor  may  be  conducted  into  the  same  quantity  of 
Nessler's  reagent.  If  lactic  acid  is  present,  it  gives  rise 
to  the  iodoform  reaction  (clouding  and  odor  of  iodoform) 
with  the  iodin  mixture.  If  Nessler's  reagent  is  used, 
yellowish-red  aldehyd  of  mercury  appears. 

This  is  a  good  and  reliable  test,  but,  as  will  be  understood, 
requires  considerable  technic  and  great  care  to  perform  it 
successfully.  For  this  reason,  it  is  not  often  available  to 
the  general  practitioner,  and  is  clinically  impractical. 

The  presence  of  lactic  acid  in  a  test-meal  may  or  may  not 
possess  significance.  I  might  say,  however,  that  when  a 
test -breakfast  or  test-dinner  is  taken  under  proper  condi- 
tions, which  admit  of  only  traces  of  lactic  acid,  and  this 
acid  is  found  in  appreciable  quantities,  it  is  of  pathologic 
significance,  and  indicates  either  subacidity  or  stagnation. 
The  impression  prevails  in  certain  quarters  that  the  pres- 
ence of  lactic  acid  is  pathologic  of  cancer.  This  is  putting 
it  too  strongly.  It  may  fairly  be  stated  that  conditions 
existing  in  the  presence  of  cancer  are  favorable  for  the 
presence  of  lactic  acid,  and  that  finding  this  acid  is  only  one 
of  several  indications  that  point  the  diagnostic  finger  to- 
ward cancer. 

Volatile  Acids. — Fatty  or  volatile  acids  are  recognized 
by  boiling  a  small  amount  of  the  gastric  filtrate  in  a  test- 
tube.  A  strip  of  moistened  blue  litmus  paper  is  held  over 
the  tube  so  that  the  vapor  will  come  in  contact  with  it  but 
not  the  boiling  filtrate.  The  paper  turns  red  if  volatile 
acid  is  present. 

Either  butyric  or  acetic  acid  can  be  recognized  by  their 
odor  in  the  gastric  contents  when  present  in  an  appreciable 
quantity.     Such  a  small  amount  of  butyric  acid  will  throw 


EXAMINATION   OF   STOMACH   CONTENTS  55 

out  such  a  characteristic  odor  of  spoiled  butter,  that  any 
other  test  is  hardly  necessary. 

Should  the  acetic  acid  be  present  in  only  small  amount, 
it  can  be  determined  by  Einhorn's  test  of  neutralizing  the 
watery  residue  of  the  ethereal  extract  of  the  gastric  filtrate 
with  carbonate  of  soda,  and  then  adding  neutral  chlorid 
of  iron.  The  presence  of  acetic  acid  is  shown  by  develop- 
ment of  a  red  color. 

Propeptone. — -Add  to  the  gastric  filtrate  about  5  c.c.  of 
the  saturated  solution  of  sodium  chlorid.  A  small  amount 
of  the  former  is  sufficient.  If  propeptone  is  present,  it 
will  be  precipitated;  if  no  precipitation  occurs,  add  one  or 
two  drops  of  acetic  acid,  and  a  precipitation  will  take  place 
in  the  presence  of  propeptone,  which  clears  up  on  heating, 
but  becomes  turbid  on  cooling. 

Peptone. — After  filtering  out  the  propeptone,  take  2  c.c. 
of  the  gastric  filtrate,  and  make  it  strongly  alkaline  by 
adding  sodium  hydroxid  solution.  Then  add  a  few  drops 
of  a  weak  i  per  cent,  copper  solution.  Peptone  gives  a 
purple  or  violet-red  color. 

Pepsin.— A  thin  disk  of  the  white  of  a  hard-boiled  egg, 
weighing  about  i  gram  (i  cm.  in  diameter  and  i  mm.  thick) 
is  placed  in  a  test-tube  containing  about  5  c.c.  of  the  gastric 
filtrate.  This  should  be  kept  at  blood  temperature,  and  a 
most  convenient  method  is  by  the  use  of  a  thermos  bottle. 

If  free  hydrochloric  acid  is  not  present  in  the  filtrate,  add 
two  drops  of  dilute  hydrochloric  acid.  The  presence  of 
pepsin  will  cause  a  disappearance  of  the  albumen  in  from 
two  to  six  hours. 

Most  of  the  methods  for  quantitative  determination  of 
pepsin  are  too  complicated  for  the  physician,  unless  he  has 
special  experience  in  a  chemical  laboratory.  The  simplest 
one  that  has  come  to  my  notice  is  one  devised  by  Henry 
Illoway,  and  which  is  sufficiently  exact  for  all  practical 
purposes. 

Ten  cgm.,  exact  weight,  of  egg-albumen  (white  of  hen's 
egg)  is  coagulated  in  the  following  manner: 


-56  DIAGNOSTIC   METHODS 

The  egg  is  placed  in  a  pot  of  cold  water,  which  is  then 
covered  with  a  lid  and  put  on  to  boil.  It  is  allowed  to  cook 
for  ten  minutes  after  the  water  has  begun  to  boil — in  all  it 
should  be  heated  twenty  minutes  from  the  time  it  has  been 
put  on.     The  egg  is  then  taken  out  and  allowed  to  cool. 

So  that  the  gastric  filtrate  may  act  on  the  albumen  in  the 
same  way  as  food  in  the  stomach,  the  cube  is  cut  in  half. 
The  filtrate  can  then  act  on  eight  sides  instead  of  four. 

This  coagulated  albumen  is  now  put  into  10  c.c.  of  gastric 
filtrate  (from  stomach  contents  extracted  one  hour  after 
ingestion  of  an  Ewald-Boas  test-meal)  and  this  is  placed  in 
a  thermostat  which  is  kept  at  38°  C. 

The  time  in  which  the  10  cgm.  are  digested,  entirely, 
partially,  or  not  at  all,  will  give  a  correct  idea  as  to  the 
status  of  the  pepsin  secretion  in  the  case  under  examina- 
tion. lUoway  has  shown  that  normal  digestion  of  the  albu- 
men requires  from  five  to  five  an  one-half  hours. 

His  classification  is  as  follows : 

Hyperpepsinia. — Digestion  requiring  only  from  three  to 
four  hours,  not  in  any  pathologic  sense  necessarily,  but  only 
to  indicate  a  secretion  of  pepsin  greater  than  usual,  which, 
however,  may  be  the  normal  in  that  individual  case. 

Normal  Pepsinia.— Digestion  of  the  albumen  requiring 
from  five  to  five  and  one-half  hours. 

Hypopepsinia. — Digestion  requiring  more  than  the  usual 
time.  The  degree  of  this  condition  is  indicated  by  the 
number  of  hours  required  beyond  the  standard  of  time. 

Apepsinia. — No  change  in  nor  digestion  of  the  albumen. 

Another  method  often  used  is  that  of  Mett.  This  con- 
sists in  sucking  fresh  egg-albumen  into  capillary  tubes°*of 
I  or  2  mm.  in  diameter,  coagulating  the  albumen  by 
boiling,  and  then  cutting  off  portions  of  the  tube  3  to  5  cm. 
long,  and  placing  these  pieces  in  the  gastric  contents.  These 
pieces  should  be  kept  in  the  incubator  at  body  temperature 
for  ten  hours.  At  the  end  of  this  time  each  end  of  the  tube 
should  show  a  lack  of  albumen  which  has  been  digested 
away,  while  some  of  the  solid  albumen  will  remain  in  the 


EXAMINATION    OE    STOMACH   CONTENTS  57 

center  of  the  tube.  Both  the  empty  portions  of  the  tube 
and  the  portion  that  is  full  are  measured,  and  the  activity 
of  the  pepsin  digestion  thus  determined.  The  relative 
amount  of  pepsin  varies  according  to  the  square  of  the 
length  of  the  empty  portion  of  the  tube,  the  figures  of  the 
latter  being  expressed  in  millimeters;  thus  3  mm.  of 
digestion  equals  nine  parts  of  pepsin;  2  mm.  equals  four 
parts  of  pepsin,  etc. 

Rennin. — Add  five  drops  of  the  gastric  filtrate  to  10  c.c. 
of  fresh  neutral  milk  in  a  test-tube.  Some  advise  neutral- 
izing the  gastric  filtrate  with  decinormal  sodium  hydroxid 
solution,  but  this  is  not  necessary.  Place  the  tube  of  milk 
in  a  glass  of  warm  water  at  a  temperature  of  about  100°  F., 
or  in  a  thermostat.  A  thermos  bottle  will  also  answer, 
and  is  both  cheap  and  convenient. 

Normal  Rennin. — Coagulation  will  occur  in  five  to  fifteen 
minutes  if  the  rennin  content  be  normal. 

Deficient  Rennin. — If  five  drops  of  the  gastric  filtrate 
give  no  result,  add  i  c.c.  of  the  filtrate  to  5  or  10  c.c.  of  the 
sweet  milk  under  the  same  conditions.  If  no  coagulation 
occurs  in  fifteen  to  thirty  minutes,  rennin  may  be  consid- 
ered deficient. 

Absence  of  Rennin.— When  no  reaction  is  obtained  in 
half  an  hour  with  5  c.c.  of  gastric  filtrate  in  10  c.c.  of  milk, 
rennin  may  be  considered  absent. 

It  has  been  demonstrated  by  more  than  one  observer 
that  rennin  is  in  nearly  normal  amount  when  pepsin  is 
deficient  or  absent,  and  it  has  also  been  shown  that  rennin 
is  one  of  the  last  elements  in  the  process  of  gastric  digestion 
to  disappear. 

Starch  Digestion. — The  orderly  progress  of  starch  diges- 
tion can  be  followed  and  the  different  stages  separated  with 
probably  more  exactitude  than  any  other  physiologic  di- 
vision of  general  digestion. 

In  a  recent  trial  of  a  murder  case  in  Atlanta,  Ga.,  one  of 
the  most  vital  factors  in  fixing  the  time  of  the  death  of  the 
victim  was  the  fact  that  starch  digestion  in  her  stomach 


58  DIAGNOSTIC  METHODS 

had  reached  the  erythrodextrin  stage.  This,  in  addition 
to  the  fact  that  no  free  acid  was  present,  fixed  the  time  of 
her  death  with  almost  absolute  certainty  at  less  than  an 
hour  after  she  had  eaten  a  carbohydrate  meal. 

The  first  step  in  starch  digestion  begins  in  the  mouth 
through  the  action  of  the  ptyalin.  It  has  been  thought 
that  the  action  of  ptyalin,  which  transforms  starch  into 
maltose  and  dextrose,  was  halted  practically  as  soon  as 
there  was  a  free  secretion  of  acid  in  the  stomach.  Later 
physiologic  experiments  have  proved  that  the  action  of  the 
ptyalin  continues  uninterruptedly  in  that  portion  of  the 
stomach  contents  unaffected  by  the  acid,  and  does  not 
cease  until  the  whole  contents  have  lost  their  alkaline 
reaction. 

The  first  of  starch  digestion,  therefore,  is  denominated 
Amylodextrin  or  AmiduUn,  giving  a  light,  but  distinct  blue 
with  Lugol's  solution. 

Erythrodextrin. — Gradually,  as  the  inversion  progresses, 
the  color  produced  by  the  Lugol's  solution  becomes  violet 
blue,  violet,  red  violet,  red,  or  mahogany  brown.  This 
varied  color  change  is  why  the  continued  inversion  is  called 
erythrodextrin. 

Achroodextrin. — With  continued  action  of  the  ptyalin, 
a  stage  is  reached  in  which  Lugol's  solution  produces  no 
color  reaction ;  this  is  called  achroodextrin,  meaning  with- 
out color.  Amylodextrin  is  precipitated  by  tannic  acid  and 
alcohol,  while  erythrodextrin  and  achroodextrin  are  pre- 
cipitated by  alcohol  and  ether,  not  by  tannic  acid.  These 
two  dextrins  do  not  reduce  Fehling's  solution,  nor  do  they 
ferment  with  yeast. 

Maltose. — This  is  soluble  in  alcohol,  insoluble  in  ether. 
It  reduces  Fehling's  solution,  but  does  not  ferment  with 
yeast. 

Dextrose. ^ — This  is  insoluble  in  alcohol  and  ether  and 
ferments  readily  with  yeast. 

These  reactions  are  quite  important,  as  they  enable  the 
physician  to  not  only  determine  the  degree  of  starch  con- 


EXAMINATION    OF    STOMACH   CONTENTS  59 

version  in  cases  of  hyperacidity  and  hypersecretion,  but 
also  enables  the  observer  to  state  with  a  fair  degree  of  ac- 
curacy how  long  a  meal  has  been  taken.  This,  as  has  been 
noted  above,  may  become  a  question  of  medico-legal 
importance. 

Occult  Blood. — The  presence  or  absence  of  occult  blood 
in  the  gastric  contents  is  of  weighty  diagnostic  import.  In 
several  conditions,  either  malignant  or  benign,  the  knowl- 
edge concerning  occult  blood  is  sufficient  to  name  the  diag- 
nosis ;  while  in  feces  also  its  presence  is  suggestive  of  various 
pathologic  states. 

There  have  been  many  tests  devised  for  the  detection  of 
occult  blood  in  the  gastric  contents  and  feces,  and  I  will 
endeavor  to  give  several  of  the  most  practical  and  reliable. 

The  simplest  test  is  performed  with  benzidin  paper,  which 
is  immersed  in  the  gastric  filtrate,  and  then  has  a  few  drops 
of  hydrogen  peroxide  poured  over  it.  After  drying  a  short 
time,  the  paper  turns  blue  in  the  presence  of  occult  blood. 
This  is  feasible  when  there  is  rather  a  large  amount  of  occult 
blood  present,  and  the  paper  can  be  kept  perfectly  dry. 
Moisture  on  the  hands  of  the  examiner,  or  a  moist  atmos- 
phere in  the  room  renders  this  test  unreliable. 

In  the  detection  of  occult  blood,  it  is  recognized  that 
many  of  the  red  corpuscles  are  degenerated  and  broken 
down,  especially  in  the  feces  after  the  blood  has  passed 
through  the  whole  intestinal  canal.  The  hematin  crystals 
remain,  however,  and  these  respond  to  the  tests. 

A  general  plan  of  extraction  of  the  hematin  is  advisable, 
and  this  is  accomplished  by  rubbing  up  with  half  a  test-tube 
of  the  gastric  filtrate,  of  the  same  amount  of  a  watery 
extract  of  the  feces,  one-third  its  volume  of  glacial  acetic 
acid  and  one-half  its  volume  of  ether.  The  mixture  is 
well  shaken,  and  allowed  to  separate.  Should  this  be  slow, 
a  few  drops  of  methyl  alcohol  will  hasten  the  separation. 
The  clear  supernatant  ether  contains  the  hemoglobin,  and 
should  be  poured  off  for  the  other  examinations. 

It  is  well  not  to  depend  on  any  single  test,  but  to  perform 


6o  DIAGNOSTIC   METHODS 

two  or  more  with  the  ethereal  extract,  if  sufficient  is  at 
hand. 

Guaiac  Test. — This  is  a  fairly  satisfactory  test,  but 
hardly  as  reliable  as  the  aloin.  It  is  accomplished  by  the 
oxidation  of  the  guaiaconic  acid  in  the  presence  of  blood  into 
a  guaiac  blue.  A  fresh  alcoholic  solution  of  guaiac  is  made 
by  scraping  with  a  knife  a  few  grains  of  old  gum  guaiac  into 
a  test-tube  containing  about  5  c.c.  of  alcohol.  (The  area 
of  guaiac  containing  the  yellow  particles  is  the  most  sensi- 
tive solution  for  the  reagent.)  To  the  alcoholic  guaiac 
solution  is  added  about  2  c.c.  of  hydrogen  peroxid,  and  the 
contents  shaken.  To  this  mixture  is  added  i  c.c.  of  the 
acetic-etherial  extract,  and  in  the  presence  of  occult  blood 
a  blue-violet  color  will  appear  in  the  upper  part  of  the 
mixture,  or  in  the  whole  mixture  if  much  occult  blood  is 
present.  This  blue  will  fade,  if  the  mixture  is  allowed  to 
stand  for  some  time.  In  the  examination  of  feces  contain- 
ing blood,  a  purplish-brown  color  may  be  observed  due  to 
both  the  blood  and  the  urobilin  contained  in  the  extract. 
Should  no  blood  be  present,  no  color  would  appear,  unless 
a  faint  brown  from  the  urobilin. 

Aloin  Test. — This  test  is  probably  the  most  dependable 
of  the  various  ones  advocated.  The  reagent  is  prepared  as 
follows:  In  a  test-tube  about  one-third  filled  with  70-per 
cent,  alcohol,  a  small  amount  of  powdered  aloin  is  placed 
(about  as  much  as  will  go  on  the  tip  of  a  knife  blade) ,  and 
allowed  to  dissolve.  About  3  c.c.  of  the  acetic-etherial 
extract  is  placed  in  a  tube,  to  which  an  equal  amount  of 
the  aloin  solution  is  added.  This  mixture  is  then  treated 
with  about  2  c.c.  of  thoroughly  ozonized  turpentine,  or  an 
equal  amount  of  hydrogen  peroxide.  (The  turpentine  is 
better.)  Ozonized  turpentine  is  prepared  by  allowing 
chemically  pure  turpentine  to  stand  exposed  to  the  air  for 
about  a  mouth.  The  above  mixture  is  thoroughly  shaken, 
and,  if  blood  is  present,  the  reaction,  a  cherry  red,  will 
appear  in  the  lower  part  or  all  of  the  solution  in  a  short 
time.     To  make  it  more  delicate,  the  ozonized  turpentine 


EXAMINATION   OF    STOMACH   CONTENTS  6 1 

may  be  added  drop  by  drop,  and  the  color  will  show  more 
deeply  in  the  lower  part  of  the  mixture.  This  test  must 
not  be  allowed  more  than  fifteen  minutes  to  develop,  for 
after  that  time  a  reddish  color  may  show,  even  if  no  blood 
is  actually  present  in  the  specimen. 

Adler's  Benzidin  Test. — This  is  quite  a  satisfactory  test 
of  stomach  contents  after  an  Ewald-Boas  test-meal,  but 
is  not  reliable  for  testing  the  feces,  as  it  may  react  from  such 
substances  as  potato,  milk  or  farina,  or  other  cereals  as  they 
pass  down  the  intestinal  canal.  This  reagent  is  prepared 
by  dissolving  as  many  benzidin  crystals  as  will  lie  on  the 
end  of  a  spatula  in  one-third  of  a  test-tube  of  70-per  cent, 
alcohol.  When  the  crystals  are  dissolved,  an  excess  of 
hydrogen  peroxide  is  added  (about  one-fourth  of  the 
amount) ,  and  to  the  top  of  this  the  acetic-ethereal  extract 
is  added.  When  blood  is  present  an  intense  green  color  is 
quickly  in  evidence,  and  when  absent,  only  a  milky  white 
appears. 

Iron  Test. — This  test  is  valuable,  if  the  patient  is  not 
taking  an  iron  preparation.  It  is  quite  sensitive,  and  is 
produced  by  placing  a  small  amount  of  unfiltered  gastric 
contents  in  a  porcelain  dish,  with  a  pinch  or  two  of  potas- 
sium chlorid  and  a  few  drops  of  concentrated  hydrochloric 
acid,  mixing  these  well,  and  heating  the  contents  over  a 
small  flame  sufficiently  to  drive  off  the  water  and  chlorin, 
and  obtain  a  perfectly  dry  residue.  To  this  a  few  drops  of 
a  diluted  solution  of  potassium  ferrocyanide  are  added,  and 
when  blood  is  present,  the  color  of  Prussian  blue  is  apparent. 

Spectroscope. — -The  spectroscope  is  advocated  by  some 
for  the  detection  of  fresh  blood  in  the  gastric  contents,  but 
it  has  no  advantage  over  the  previous  tests  mentioned, 
beside  being  open  to  the  possibility  of  gross  errors  if  wrongly 
interpreted. 

When  blood  has  been  in  the  stomach  or  intestines  any 
length  of  time,  it  is  dark  or  black  in  appearance,  and  never 
red,  unless  poured  out  in  large  quantities  and  ejected 
quickly.     There    are    few    pathologic    expressions    more 


62  DIAGNOSTIC   METHODS 

dramatic  and  fear-inspiring  than  the  appearance  of  blood 
in  the  vomitus  or  stools.  Patients  may  put  off  treatment 
of  their  ailments  from  time  to  time,  but  when  there  is 
hematemesis  or  intestinal  hemorrhage,  aid  is  quickly  and 
urgently  sought.  Blood  in  the  stomach  contents  is  found 
most  often  in  gastric  ulcer  or  cancer.  It  is  sometimes 
present  in  benign  stenosis,  and  occasionally  in  chronic 
gastritis  from  catarrhal  ulcers.  It  may  also  arise  from 
multiple  erosions  in  the  course  of  alcoholic  gastritis,  or 
following  an  alcoholic  debauch.  It  is  not  uncommon  in 
cirrhosis  of  the  liver,  and  passive  congestion  due  to  portal 
obstruction,  or  heart  or  lung  disease.  It  may  arise  from 
aneurysm  into  the  esophagus  or  stomach,  in  severe  anemia 
or  hemophilia,  scurvy,  purpura  hemorrhagica,  Hodgkin's 
disease,  typhus  or  yellow  fever,  malignant  small-pox,  or  in 
pernicious  malarial  fever,  or  hemorrhagic  scarlet  fever. 
It  may  follow  traumatism,  and  occult  blood  is  not  infre- 
quently found  in  the  stomach  contents  from  inexpert 
extraction  or  the  use  of  an  improper  stomach  tube.  It 
must  not  be  forgotten,  also,  that  the  blood  may  not  orig- 
inate in  the  stomach  or  esophagus,  but  may  be  swallowed 
from  a  pulmonary  or  nasal  hemorrhage.  Patients  have 
had  slight  hemorrhages  of  this  sort  during  sleep,  have 
unconsciously  swallowed  the  blood,  and  mistaken  diagnoses 
of  diseased  conditions  of  the  stomach  or  intestinal  tract 
have  been  perpetrated.  When  testing  for  blood,  either 
visible  or  occult,  the  physician  should  ever  be  on  the  alert 
as  to  its  origin,  lest  grave  errors  as  to  diagnosis  and  conse- 
quent treatment  becloud  his  viewpoint. 

Bile  and  Intestinal  Juices  in  the  Stomach. — The  presence 
of  bile  in  the  stomach  may  be  due  to  stenosis  of  the  intes- 
tines, to  excessive  vomiting  in  migraine,  or  to  excessive 
vomiting  from  dietetic  errors — in  fact,  bile  will  appear  in 
the  stomach  after  laborious  vomiting  from  any  cause. 

An  extremely  small  amount  of  bile  will  show  itself  in  the 
gastric  contents  or  lavage  water,  and  a  special  test  is 
seldom    necessary.     Sould    a   test    be    desired,    however, 


EXAMINATION    OF    STOMACH   CONTENTS  63 

there  may  be  added  to  2  c.c.  of  the  gastric  contents  i  c.c.  of 
fuming  nitric  acid.     The  presence  of  bile  turns  this  green. 

The  examination  of  the  intestinal  juice  may  with  pro- 
priety be  considered  under  the  heading  of  examination  of 
the  duodenal  contents.  There  are  no  intestinal  juices 
normally  in  the  stomach,  and  their  presence  there  is  due  to 
the  same  causes  as  the  presence  of  bile. 

Character  and  Significance  of  Gastric  Mucus. — A  small 
amount  of  mucus  and  saliva  is  normally  always  present 
in  the  fasting  stomach,  and  a  certain  amount  admixed  with 
the  contents  of  a  full  stomach.  The  mucus  in  test-meals 
is  found  both  well  mixed  with  the  substance  of  the  meal  and 
in  a  free  form  floating  in  coagulated  lumps  on  the  top. 
That  finely  mixed  is  the  gastric  mucus,  secreted  by  the 
glands  of  the  stomach  and  combined  with  the  mucin  con- 
stituents of  the  saliva.  The  other  form  of  mucus  is  caused 
by  irritation  from  the  stomach-tube,  or  is  swallowed  mucus, 
originating  in  the  mouth,  pharynx  or  naso-pharynx.  In 
patients  with  post-nasal  catarrh  there  is  being  uncon- 
sciously swallowed  much  of  the  time  quantities  of  thick 
glairy  mucus,  which  is  easily  visible  to  the  eye  in  the 
stomach  contents.  Unless  this  mucus  is  septic  itself,  or 
unless  it  is  taken  into  an  achylic  stomach,  it  has  but  little 
local  diagnostic  significance. 

The  detection  of  excess  mucus  in  test-meals  has  been 
discussed. 

Examination  of  Duodenal  Contents. — Many  have  been 
the  methods  for  obtaining  the  duodenal  juices,  both  direct 
and  indirect.  Boas  first  obtained  them  by  massaging  the 
empty  stomach  in  the  duodenal  region,  forcing  the  juice 
into  the  stomach,  and  extracting  it  with  a  stomach-tube. 
Hemmeter  and  Kuhn  endeavored  to  pass  a  small  stomach- 
tube  directly  into  the  duodenum,  but  were  not  very  success- 
ful. Einhorn  used  the  duodenal  bucket  with  a  certain 
measure  of  success,  though  the  amount  of  juice  secured 
was  insignificant  in  quantity.  He  also  endeavored  to 
catheterize  the  duodenum. 


64  DIAGNOSTIC   METHODS 

Later  on  both  Einhorn  and  M.  Gross,  independently,  but 
about  the  same  time,  devised  a  method  by  which  in  the 
majority  of  cases  the  duodenal  contents  may  be  obtained. 

The  Gross  tube  consists  of  a  perforated  round  metal  ball 
about  twice  the  size  of  a  pea,  to  which  is  attached  a  thin, 
flexible  rubber  tube  0.2  cm.  in  diameter  and  125  cm.  in 
length,  marked  every  10  cm.  To  this  is  attached  a  glass 
bulb,  which  is .  connected  by  a<  length  of  tubing  with  a 
mouth-piece,  which  the  operator  can  use  to  aspirate  with 
his  own  mouth,  or  to  which  an  aspirating  bulb  may  be 
attached. 

Gross  advises  the  following  method : 

Test-meal. — The  patient  is  given  in  the  morning  a 
tumblerful  of  equal  parts  of  milk  and  water.  This  mixture 
causes  but  little  flow  of  hydrochloric  acid,  but  contains 
sufficient  fat  to  stimulate  the  pancreatic  secretions. 
Half  an  hour  later  the  duodenal  tube  is  introduced.  The 
patient  should  swallow  the  ball  and  tube,  previously  wet 
in  water,  until  the  mark  45  cm.  reaches  the  lips.  Then 
blow  slightly  through  the  tube  into  the  stomach  so  as  to 
smooth  the  tube  out  and  cause  it  to  hang  freely  in  the  stom- 
ach cavity.  The  patient  should  then  lie  down  slowly,  turn 
over  on  the  right  side,  in  which  position,  after  a  few  minutes, 
the  tube  is  permitted  to  glide  down  through  the  mouth 
without  swallowing,  following  the  pull  of  the  ball  until  the 
60  cm.  has  been  reached.  After  five  or  ten  minutes  the 
aspiration  may  be  begun,  and  it  should  show  contents  of 
a  sHghtly  yellow  tint.  The  patient  should  remain  with  the 
mouth  partly  open,  but  should  make  no  swallowing  move- 
ments. The  tube  will  gradually  descend  to  the  65  or 
70  cm.  mark. 

A  second  aspiration  may  now  be  made,  and  usually  a 
yellowish  liquid,  free  from  casein,  will  appear,  giving  a 
weakly  acid  reaction.  By  waiting  a  while,  and  making 
several  aspirations,  the  yellow  aqueous  contents  of  the 
duodenum  will  usually  be  secured,  giving  a  neutral  or 
alkaline  reaction,    and   sometimes   exhibiting   a   greenish- 


METHODS    OF    OBTAINING   DUODENAL    CONTENTS  65 

yellow  fluorescence.  Occasionally  the  aspirated  fluid  re- 
mains acid,  perhaps  due  to  hyperchlorhydria,  and,  therefore 
neutralization  of  the  duodenal  contents  may  necessarily 
take  place  lower  down.  As  a  check,  give  a  cup  of  coffee 
with  the  tube  in  place.  Aspiration  should  then  be  per- 
formed, and  if  the  fluid  is  still  green,  the  contents  are  duo- 
denal. By  withdrawing  the  tube  a  short  distance  and 
aspirating,  coffee  is  drawn  out.  Gross  affirms  that,  unless 
there  is  some  mechanical  obstacle  to  the  passage  of  the  ball 
through  the  pylorus,  that  the  duodenum  will  usually  be 
reached  and  the  contents  successfully  aspirated  in  an  hour. 

Einhorn's  Duodenal  Pump. — This  has  some  advantages 
over  the  one  just  described,  in  that  it  may  be  used  for  both 
aspirating  purposes,  for  duodenal  lavage,  or  for  duodenal 
alimentation.  The  illustration  makes  its  workings  quite 
clear.  It  has  three  markings — 40  cm.  (cardia),  56  cm. 
(pylorus),  and  70  to  80,  distance  from  the  capsule.  The 
duodenal  contents  are  aspirated  out  by  the  syringe,  the 
cock  turned,  they  are  then  ejected  into  a  vessel,  and  so  on. 

Einhorn's  Method. — The  patient  in  a  fasting  condition 
drinks  a  cup  of  tea  with  sugar  but  no  milk,  and  then  about 
half  an  hour  later  the  capsule  and  tube  (previously  lubri- 
cated in  water)  are  swallowed.  The  swallowing  may  be 
assisted  by  drinking  half  a  glass  of  water.  To  be  sure  that 
the  tube  is  in  the  stomach  and  is  not  kinked,  a  little  fluid 
may  be  aspirated  to  determine  its  reaction.  A  syringeful 
of  water  is  then  forced  into  the  tube,  followed  by  one  of  air, 
the  tube  is  shut  off  by  the  stop-cock,  and  the  thread  with 
rubber  hitched  over  the  ear.  The  patient  should  not 
close  the  lips  or  teeth  for  a  while,  and  should  quietly  wait 
about  an  hour  for  the  tube  to  penetrate  the  duodenum. 

When  the  tube  reaches  about  the  70  cm.  mark  at  the 
lips,  aspiration  is  begun.  If  the  perforated  capsule  is  in 
the  duodenum,  on  aspirating  there  is  obtained  a  golden- 
yellow  watery  fluid,  somewhat  viscid,  and  of  alkaline  reac- 
tion. Einhorn  recommends  that  when  the  flow  commences, 
the  piston  of  the  syringe  should  be  removed,  and  by  keeping 
5 


66  DIAGNOSTIC  METHODS 

the  barrel  of  the  syringe  low,  the  liquid  should  be  siphoned 
out.  This  I  have  attempted  a  number  of  times  without 
success,  and,  while  it  may  be  practicable  in  the  experienced 
hands  of  Einhorn,  any  one  less  expert  will  find  it  necessary 
to  continue  the  aspiration  in  order  to  obtain  the  duodenal 
juices. 

At  times  the  tube  coils  in  the  stomach,  and  does  not  enter 
the  duodenum.  If  the  fluid  obtained  is  acid,  withdraw  the 
tube  to  the  56  cm.  mark,  wash  it  out  with  water,  blow  air 
through  it,  and  in  half  an  hour  the  attempt  may  again  be 
made.  When  the  tube  lies  in  the  stomach,  it  does  not 
collapse  on  aspiration;  when  it  is  in  the  duodenum,  however, 
it  collapses  on  aspiration,  and  the  flow  of  fluid  is  much 
slower.  As  a  further  test,  a  little  milk  may  be  given, 
and,  if  no  milk  is  aspirated,  it  may  be  safely  assumed  that 
the  tube  is  in  the  duodenum. 

There  are  some  stomachs  in  which  the  conformation  does 
not  lend  itself  to  the  progress  of  the  tube  into  the  duodenum, 
and  in  others  the  pylorus  may  be  stenosed,  or  in  other  ways 
obstruct  the  passage  of  the  tube.  In  the  great  majority 
of  individuals  a  certain  amount  of  patience  and  persever- 
ance will  enable  the  physician  to  obtain  the  undiluted 
duodenal  juices. 

Examination  of  the  Duodenal  Juices. — The  test  for  bile 
has  been  mentioned  and  it  may  be  tested  in  the  same  man- 
ner as  in  the  stomach. 

Steapsin. — Take  one  drop  of  neutral  milk,  two  drops  of 
water,  and  two  or  three  drops  of  the  duodenal  contents. 
The  last  named  should  be  neutralized  if  the  reaction  is  acid. 
Place  this  small  amount  of  fluid  in  a  small  test-tube,  and 
keep  it  at  the  temperature  of  the  body.  Put  in  this  a  mi- 
nute piece  of  blue  litmus  agar,  and  in  twenty  minutes  this 
should  turn  red  from  the  development  of  fatty  acids.  As 
has  been  previously  mentioned,  a  thermos  bottle  will 
serve  fully  as  well  as  an  expensive  incubator. 

Trypsin. — If  the  duodenal  fluid  is  acid,  neutralize  it,  and 
place  in  it  a  small  piece  of  a  hard-boiled  egg.     Keep  this 


EXAMINATION   OF   DUODENAL   JUICES  67 

two  or  three  hours  at  blood  temperature.     If  trypsin  is 
present,  the  albumen  will  be  dissolved. 

Amylopsin. — To  test  for  this,  use  a  boiled  starch  solution 
or  prepared  starch  paper.  Mix  the  duodenal  contents  with 
the  starch  solution,  or  insert  in  it  a  narrow  strip  of  starch 
paper,  and  leave  it  for  a  while  at  blood  teniperature.  In 
about  an  hour  add  a  weak  iodin  solution,  and,  if  dextrin  is 
present,  a  red  color  is  developed. 

Another  test  for  amylopsin  in  which  a  quantity  of  a  i  per 
cent,  solution  of  Kaulbaum's  soluble  starch,  heated  in  an 
incubator  to  55°  c.  A  number  of  test-tubes  are  heated  up, 
and  5  c.c.  are  put  in  a  hot  tube,  to  which  five  drops  of  the 
duodenal  juice  are  added.  This  is  shaken  for  about  a 
minute,  and  1/2  c.c.  of  a  250th  normal  iodin  solution  is 
then  added.  The  normal  iodin  solution  consists  of  an 
aqueous  solution  of  equal  parts  of  iodin,  iodid  of  soda,  iodid 
of  potassium,  and  iodid  of  ammonium,  i  to  250. 

If  no  amylopsin  is  present,  the  solution  becomes  blue;  or 
green  if  bile  is  present ;  if  amylopsin  is  normal,  a  pale  pink ; 
if  in  excess,  it  is  colorless. 

M.  Gross  has  investigated  the  duodenal  juices  to  a 
considerable  extent,  and  has  drawn  certain  conclusions 
from  a  microscopical  examination  of  them.  To  quote 
him:  "The  microscopic  inspection  of  the  duodenal  con- 
tents, as  gathered  with  the  aid  of  aspiration  in  the  receptacle 
of  the  instrument,  enables  one  after  a  short  experience  to 
draw  certain  conclusions  as  to  the  part  of  the  duodenum 
from  which  the  fluid  emanates.  Thus,  in  the  pars  superior 
duodeni,  the  contents  are  more  likely  to  resemble  gastric 
contents,  although  there  are  already  all  the  characteristics 
of  the  duodenal  contents,  such  as  reaction,  color,  and  oft- 
times  ferments  (secondary  stomach,  'Nachmagen')-  A 
few  centimeters  lower  down,  but  still  above  the  caruncle 
(papilla  of  Vater)  they  have  all  the  properties  of  pure  duo- 
denal contents,  that  is,  they  are  alkaline,  limpid,  viscid, 
fluid,  light  yellow  to  green  or  golden  yellow;  in  rare  cases 
it  is  even  possible  to  obtain  pure  duodenal  secretion,  or 


68  DIAGNOSTIC   METHODS 

rather  intestinal  secretion,  i.e.,  without  the  admixture  of 
bile.  The  fluid  has  a  lighter  color,  scarcely  yellow.  In 
the  pars  inferior,  a  few  centimeters  lower  still  and  below  the 
caruncle,  the  duodenal  contents  may  show  the  same  char- 
acteristics as  above  the  caruncle,  but  when  the  stomach  is 
empty  in  irregular  and  infrequent  intervals,  the  duodenal 
contents  will  contain  also  a  wave  of  the  characteristic 
bladder  contents.  In  normal  conditions,  under  the  stimu- 
lation of  ingested  food,  the  inspissated  bladder  bile,  mixed 
with  the  now  abundantly  secreted  liver  bile,  flows  freely 
into  the  duodenum  at  the  beginning  of  digestion,  and  at 
the  opening  of  the  so-called  duodeno-choledochal  sphincter. 
When,  however,  this  sphincter  is  closed,  there  is  an  obstacle 
to  the  flow  of  bile,  compelling  it  to  take  its  course  through 
the  cysticus  and  gall-bladder." 

Our  practical  knowledge  of  the  various  modifications 
of  the  duodenal  contents  and  intestinal  juices  is  far  from 
satisfactory,  and  much  is  yet  to  be  learned  concerning  their 
bearing  on  pathologic  digestive  conditions. 

The  foregoing  methods  of  examination  of  the  stomach  and 
upper  intestinal  tracts  should  not  be  taken  singly,  but 
should  be  correlated  in  all  cases  where  the  diagnosis  is 
doubtful.  To  depend  on  any  single  diagnostic  feature  is 
unsafe  and  unscientific. 

Test-meals,  for  instance,  are  of  high  value  and  furnish  in 
many  instances  important  diagnostic  facts.  To  make  a 
diagnosis,  however,  on  the  simple  findings  of  a  test-meal, 
without  taking  into  consideration  other  symptoms  sub- 
jective and  objective,  may  lead  the  examiner  into  decided 
error. 

In  no  class  of  diseases  are  isolated  symptoms  more 
fallacious  and  misleading  than  those  of  the  digestive  system, 
and  the  reader  is  admonished  to  take  advantage  of  every 
aid,  both  clinical  and  laboratory,  so  that  the  diagnoses 
may  represent  a  large  perspective,  and  the  liability  to 
incorrect  conclusions  may  be  minimized. 


CHAPTER  III 
EXAMINATION  OF  THE  FECES 

The  intelligent  examination  of  the  feces  is  one  of  the 
most  important  aids  in  diagnosis  of  gastrointestinal  con- 
ditions, and  at  the  same  time  one  of  the  most  neglected. 
Apart  from  specialists  in  digestive  diseases,  health  officers, 
or  those  engaged  in  laboratory  investigations,  the  exami- 
nation of  normal  or  abnormal  stools  is  infrequent  and 
perfunctory. 

The  general  practitioner  should  be  familiar  with  the 
various  appearances  of  the  feces,  and  should  also  acquaint 
himself  with  the  normal  macroscopic  and  microscopic 
appearance. 

In  order  to  form  a  correct  judgment  it  is  necessary  that 
a  somewhat  fixed  standard  be  formed,  so  that  deviations 
from  this  standard  may  be  properly  interpreted. 

To  Schmidt  and  Strasburger  we  are  much  indebted  for 
painstaking  studies  and  helpful  conclusions  in  the  examina- 
tion of  feces,  and  in  "The  Test-diet  in  Intestinal  Diseases" 
by  Dr.  Adolf  Schmidt,  which  has  been  acceptably  translated 
by  Dr.  C.  D.  Aaron,  we  have  a  compact  and  excellent  pre- 
sentation of  the  subject. 

The  requirements  which  must  be  imposed  on  a  suitable 
test -diet  are  manifold.  To  quote  Prof.  Schmidt,  "It  must 
be  so  selected  that  it  can  be  taken  by  healthy  persons  as 
well  as  by  most  of  those  suffering  with  intestinal  disorders ; 
it  must  be  free  as  possible,  but  not  absolutely  free,  from 
waste  matter,  in  order  that  the  stimulus  ordinarily  furnished 
by  the  ingesta  should  not  be  completely  absent ;  it  must  be 
capable  of  supplying  the  minimum,  at  least,  of  calories 
required  by  the  body  (at  rest),  and  must  contain  the  three 
chief   groups  of    food-stuffs  in    proportionate  relation    to 

69 


70  EXAMINATION   OF   THE   FECES 

each  other;  finally,  it  must  be  of  simple  com.position,  easy 
to  make  and  uniformly  prepared.  Only  when  all  these 
general  requirements  are  fulfilled,  the  narrower  selection 
with  regard  to  the  methods  of  subsequent  fecal  examination 
can  proceed." 

There  are  certain  fundamentals  in  a  test-diet,  which 
must  not  be  neglected,  and  according  to  Schmidt,  they 
are  as  follows: 

1.  A  certain  measure  of  milk  (1/2  to  i  1/2  liters),  which, 
however,  may  be  boiled  entirely  with  the  foods; 

2.  About  100  grm.  white  bread  (or  zwieback,  cakes,  etc.) ; 

3.  A  good  portion  (100-250)  of  potato-broth; 

4.  One-fourth  pound  chopped  beef,  a  portion,  at  least, 
of  which  must  remain  raw  of  half  raw. 

These  articles  furnish  a  suitably  balanced  dietary,  and 
one  which  can  be  borne  by  any  ordinary  digestive  tract. 

The  following  is  the  detailed  test-diet,  as  recommended 
by  Schmidt  and  Strasburger: 

In  the  morning:  0.5  liter  milk  (or  if  milk  does  not 
agree,  0.5  liter  cocoa,  prepared  from  20  grm.  cocoa-powder, 
10  grm.  sugar,  400  grm.  water,  and  100  grm.  milk,  50  grm. 
zwieback. 

In  the  forenoon:  0.5  liter  oatmeal  gruel,  prepared  from 
40  grm.  oatmeal,  10  grm.  butter,  200  grm.  milk,  300  grm. 
water,  i  egg  (strained)  and  salt  to  taste. 

At  noon:  125  grm.  chopped  beef  (raw  weight),  broiled 
rare,  with  20  grm.  butter,  so  that  the  interior  will  remain 
raw.  With  this  is  given  250  grm.  potato-broth,  made  of 
190  grm.  mashed  potatoes,  100  grm.  milk,  and  10  grm, 
butter  with  some  salt. 

In  the  afternoon :     Same  as  morning. 

In  the  evening :     Same  as  in  forenoon. 

This  diet  contains  i  1/2  liters  milk,  100  grm.  zwieback, 
2  eggs,  50  grm.  butter,  125  grm.  beef,  190  grm.  potatoes, 
and  gruel  made  of  80  grm.  oatmeal.  It  contains  about 
no  grm.  albumen,  105  grm.  fat,  and  200  grm.  carbohydrates, 
and   furnishes    a   total    of    about    2247    calories,    answer- 


INTESTINAL   TEST-MEAL  7 1 

ing  the  minimum  requirements  of  an  adult  at  rest.  It 
may  be  said  in  this  connection,  however,  that  this  diet  is 
quite  a  tax  upon  deHcate  stomachs,  and  often  it  is  necessary 
to  reduce  it  in  general  quantity. 

This  diet  should  be  given  for  three  days — sometimes 
longer — until  a  stool  is  obtained,  which  with  a  certainty 
comes  from  it.  Under  normal  conditions  this  occurs  at 
the  second  defecation  after  the  inauguration  of  the  test- 
diet.  There  is  generally  no  difficulty  in  recognizing  the 
feces  arising  from  this  test-diet,  but,  if  desired,  a  capsule 
containing  about  5  grains  of  carmine  may  be  administered 
at  the  beginning  and  end  of  the  test.  This  sharply  defines 
the  test-stool,  unless  there  is  diarrhea,  in  which  event 
it  is  well  instead  to  extend  the  diet  over  a  rather  longer 
period. 

It  will  be  somewhat  obvious  that  the  above  test-diet, 
in  its  preparation  and  ingestion  presents  some  difficulties 
when  attempted  outside  of  a  well-ordered  institution,  or 
when  attempted  among  individuals  of  a  mediocre  intellect. 
To  overcome  this  I  have  made  a  modification  of  the 
Schmidt-Strasburger  test-diet,  which  can  be  easily  com- 
prehended and  applied,  not  only  in  hospitals,  but  also  in 
private  homes.  This,  too,  more  nearly  conforms  to  the 
American  custom  of  three  daily  meals,  for,  to  vary  in 
many  particulars  the  habits  of  the  patient  will  create  an 
abnormal  condition  of  the  fecal  evacuations,  thereby  de- 
feating the  object  in  view. 

My  modified  test-diet  is  as  follows : 

Morning,  coffee,  tea  or  cocoa  with  much  milk,  oatmeal 
with  milk,  one  soft-boiled  or  soft-poached  egg,  and  one 
roll  with  much  butter. 

Noon,  bouillon,  if  desired,  1/4  pound  of  lean  minced 
beef,  roasted  in  butter  (half  raw  inside),  a  liberal  plate  of 
baked  and  well-mashed  Irish  potatoes,  tea,  or  tea  with 
milk,  and  a  roll  with  a  liberal  amount  of  butter. 

Evening,  oatmeal  with  plenty  of  milk,  and  a  little  sugar, 
if  preferred,  one  or  two  eggs  cooked  any  desired  way,  except 


72  EXAMINATION    OF    THE    FECES 

hard-fried,  or,  instead  of  the  eggs,  a  moderate  portion  of 
roast  veal  or  lamb,  a  roll  with  butter,  and  tea  or  milk. 

A  sufficiency  of  water  should  be  drunk  with  this  diet,  and 
the  patient  should  be  encouraged  to  drink  water  liberally 
through  the  day. 

After  the  second  daily  defecation  follows  the  ingestion 
of  this  test-diet,  the  examination  of  the  feces  may  generally 
begin. 

Macroscopic. — This  forms  the  most  important  part  of 
the  whole  examination,  if  carefully  and  intelligently  made, 
and  alone  is  often  sufficient  to  enable  an  experienced 
investigator  to  form  a  judgment  of  intestinal  conditions. 
It  first  decides  if  color,  consistency,  and  odor  correspond 
with  normal  feces,  due  allowances  being  made  as  to  color, 
if  milk  or  cocoa  has  been  ingested.  The  former  produces 
light-brown  stool,  while  the  latter  produces  a  red-brown. 
Other  deviations  through  disease  may  be  shown  in  black, 
tarry  feces  (blood) ,  or  sticky,  clay-colored  stools  (fat) . 

The  odor  under  normal  conditions  should  be  mildly 
excrementitious,  with  the  characteristic  odor  of  human 
stools.  Under  pathologic  conditions  it  may  give  off  a  rancid 
odor  (butyric  acid)  or  a  sour  odor  (acetic  acid),  or  assume 
the  vile  odor  of  putrefaction. 

In  the  diarrhea  of  pellagra  the  feces  assume  a  char- 
acteristic odor  which  is  almost  pathognomonic.  Nurses, 
who  have  had  considerable  experience  in  the  care  of  this 
disease,  have  assured  me  that  the  diagnosis  could  in  a 
majority  of  cases  be  made  from  the  odor  of  the  stools, 
even  if  most  of  the  other  marked  symptoms  were  absent. 

There  may  also  be  noted  at  first  inspection,  gross  flakes 
of  mucus,  blood-stained  pus,  portions  of  tapeworm  or 
other  parasites,  undigested  particles  of  food,  streaks  of 
unmixed  blood,  or  any  other  foreign  bodies. 

Regarding  the  mucus,  it  is  important  to  decide  whether 
it  is  thoroughly  mixed  with  the  feces,  or  easily  separated. 
The  former  condition  would  point  to  an  origin  of  the  mucus 


MACROSCOPIC    APPEARANCE  73 

high  up;  the  latter  to  its  origin  low  down  in  the  bowel. 
The  same  may  apply  to  pus  or  blood. 

In  the  next  stage  of  the  examination  the  entire  stool 
may  be  stirred  up  with  a  spatula,  and  a  portion  about  the 
size  of  a  walnut  placed  in  a  small  mortar.  This  should  be 
well  rubbed  up,  and,  if  stiff  in  consistency,  enough  water 
may  be  added  to  soften  it  to  about  the  consistency  of  sauce. 
The  ground-up  specimen  is  then  spread  upon  a  smooth 
black  plate,  or  any  smooth  black  background.  This 
test-diet,  if  normal  will  appear  as  a  soft,  homogeneous 
-mass,  with  minute  brown  or  reddish  points. 

If  abnormal,  there  may  appear  as  food  remains,  small 
shreds  of  connective  tissue  and  tendons  from  the  chopped 
meat  eaten.  These  can  be  distinguished  from  the  mucus 
by  their  whitish  yellow  color  and  their  thread-like  appear- 
ance. If  in  doubt,  a  thread  is  placed  under  a  microscope 
and  treated  with  acetic  acid.  In  connective  tissue  the 
thread-like  structure  disappears. 

Remains  of  muscle  tissue  appear  as  small,  brown-colored 
rods,  resembling  tiny  splinters  of  wood.  These  can  be 
broken  up  by  pressure,  showing  their  muscular  structure 
under  the  microscope.  An  excess  of  undigested  muscular 
tissue  in  the  feces  points  to  disturbed  intestinal  digestion. 

The  potato  remains  appear  as  glassy,  transparent 
granules,  much  like  granules  of  mucus.  Under  the  micro- 
scope they  will  show  their  cellular  structure,  and  may  be 
colored  blue  with  iodin. 

The  fat  remains  are  light  in  color,  and  clay-like  in  con- 
sistency, and  if  in  excess  may  show  in  small,  light-yellow 
lumps. 

Mucus  in  large  amounts,  or  even  in  small,  may  and  should 
be  recognized.  Large  shreds  or  strips,  tubes,  etc.,  as  in 
the  presence  of  mucous  colic,  may  be  removed  before  the 
specimen  is  ground  up,  and  their  identification  is  easy. 
The  smaller  flakes  may  be  harder  to  recognize,  though 
Schmidt  affirms  that  there  is  no  form  of  mucus  found 
mingled  with  the  feces,  which  on  thorough  inspection  cannot 


74  EXAMINATION   OF   THE   FECES 

be  recognized  with  the  naked  eye — especially  if  some  of 
the  ground-up  mass  is  placed  on  a  glass  plate  and  held  up 
against  the  light.  The  mucus  will  then  show  as  glassy, 
transparent  flakes,  occasionally  colored  yellow  by  bili- 
rubin, with  irregular,  ragged  outlines.  If  still  in  doubt, 
the  microscope  can  always  serve  as  arbiter,  disclosing 
with  clearness  the  minute  structure  of  the  mucous-flakes. 

Occasionally  large  crystals  of  ammonio-magnesium  phos- 
phate are  present  in  putrefying  and  malodorous  feces. 
They  grate  when  the  specimen  is  being  rubbed  up  in  the 
mortar,  show  the  coffin-lid  shape  under  the  microscope, 
and  are  easily  dissolved  by  any  acids. 

MICROSCOPICAL  EXAMINATION  OF  THE  STOOLS 

For  this  examination  care  must  be  taken  in  the  selection 
of  fragments,  as  a  random  search  will  often  disclose  noth- 
ing. In  the  case  of  parasite  eggs,  etc.,  it  is  well  to  mix  the 
stool  with  water,  and  allow  the  specimen  to  sediment,  or 
to  centrifugalize  it.  Mucous  particles  are  to  be  chosen  if 
protozoa  are  the  objects  of  search.  In  searching  for  blood, 
for  instance,  it  often  makes  much  difference  whether  or 
not  the  right  particle  is  taken. 

Epithelial  Cells. — These  are  found  in  squamous  form  in 
mucus  which  covers  the  stool,  and  comes  from  the  anal 
region.  Many  of  these  cells  are  generally  present  in  cases 
of  proctitis  or  rectal  cancer.  Cylindrical  cells  are  the 
commonest  found.  They  are  easily  found  in  the  lavage 
water  of  the  rectum  and  sigmoid,  and  show  all  grades  of 
degeneration,  from  well-preserved,  even  goblet  cells  to  those 
in  which  the  nucleus  has  disappeared  absolutely.  This 
often  occurs  in  diarrhea,  and  sometimes  the  cells  are  so 
abundant  that  the  condition  is  denominated  "desquama- 
tive catarrh." 

Triple  phosphate  crystals  are  generaly  present,  ir- 
regularly formed  as  a  rule.  Calcium  phosphate  crystals 
occur  in  the  same  form  as  in  the  urine.     There  are  also 


PLATE  I. 


K^atharine  HiU 


Vegetable  Cells  found  in  Feces.      (After  Schmipt  and  Strasbueger.) 


MICROSCOPIC   EXAMINATION 


75 


calcium  salts  of  still  unknown  acids,  which  are  present  in 
irregular,  oval,  or  circular  masses,  sometimes  fissured, 
sometimes  with  a  concentric  striation,  and  always  bile 
stained.  The  calcium  soaps  and  oxalate  are  also  frequently- 
found. 

Cholesterin  is  often  present,  but  not  in  typical  crystal 
form,  requiring  a  chemical  examination  for  its  detection. 
Charcot-Leyden  crystals  have  been  noted  in  the  feces  in  a 


Fig.  3. — Normal  feces.     {Landois.) 
a,  Muscle  fibers;  h,  tendon;  c,  epithelial  cells;  d,  leucocytes,  e-i,  various  forms 
of  plani-cells,  among  which  are  large  numbers  of  bacteria;  between  h  and  h  are 
yeast-cells;  k,  ammonium- magnesium  phosphate. 

great  variety  of  diseases,  but  most  well-posted  observers 
claim  that  their  presence  indicates  some  animal  parasite, 
though  it  may  be  any,  from  the  harmless  oxyuris  to  the 
pernicious  uncinaria. 

Remnants  of  undigested  food  form  the  chief  part  of  the 
picture,  especially  the  thorn-like  spines  from  various  fruits 
and  berries.  The  remains  of  these  show  in  spiral  cells, 
with  the  veins  of  leaves  well  defined;  thick  cellulose  shells 
of  various  cells,  some  resembling  soap  masses,  some  parasite 
eggs;  and  the  elastic  tissue  from  meats.  These  heterogene- 
ous objects  can  be  readily  identified  only  after  careful  and 
intent  practice.  Experience,  however,  will  soon  enable  the 
examiner  to  readily  recognize  all  the  ordinary  constituents 


76 


EXAMINATION    OF    THE    FECES 


of  normal  or  pathologic  stools,  and  the  rarer  objects  gener- 
ally require  special  methods  for  their  detection. 

Examination  for  Gall-stones  in  the  Feces. — To  find  gall- 
stones in  the  feces  (and  a  careful  search  may  continue  for 
fifteen  days  after  the  colic)  the  stools  are  well  mixed  with 
water,  and  rubbed  through  a  sieve.     Sometimes  no  stone 


Fig.  4. — Boas'  stool-sieve.     {Hemmeler.) 

is  found,  even  when  there  have  been  typical  symptoms  of 
cholelithiasis.  In  such  a  case,  it  may  have  been  infection 
of  the  bile  ducts  and  not  a  stone  that  caused  the  pain;  or 
the  stone  may  have  remained  in  the  ampulla  of  Vater 
without  entirely  closing  the  duct ;  or,  after  engaging  in  the 
cystic  duct,  it  may  have  fallen  back  into  the  gall-bladder; 
or  it  may  have  disintegrated  in  the  intestine.  All  these 
considerations  should  be  taken  into  account  when  searching 
for  a  stone  without  success. 

The  size  of  a  gall-stone  varies  from  that  of  a  tiny  con- 


GALL-STONES  77 

cretion  to  that  of  a  pigeon's  egg.  The  single  stones  are 
usually  spherical  and  rough,  but  when  multiple,  they 
usually  have  well-defined  facettes.  When  fractured  they 
usually  show  their  formation  in  concentric  layers.  Gall- 
stones are  composed  chiefly  of  cholesterin  and  the  calcium 
salt  of  bilirubin,  with  traces  of  calcium  carbonate. 

For  analysis  the  stone  is  dried  and  powdered,  for  unless 
it  is  powdered,  the  mucous  coating  will  prevent  its  solution. 
The  powder  may  then  be  dissolved  in  alcohol  and  ether,  and 
the  cholesterin  crystallized  out  as  the  ether  evaporates. 
After  the  cholesterin  is  extracted,  the  residue  is  treated  in 
the  cold  with  very  dilute  KOH  solution.  This  will  extract 
the  bilirubin,  the  yellow  solution  of  which  will  give  Gmelin's 
test.     The  solution  will  be  blue  if  bilirubin  is  present. 

Pseudo  Gall-stones. — These  objects  have  been  the  cause 
of  many  diagnostic  errors,  and  many  have  been  the  mistakes 
in  naming  these  deceptive  concretions  real  gall-stones. 
Every  suspected  stone  should  be  fractured  and  examined 
chemically.  Among  the  deceptive  pseudo  gall-stones  may 
be  mentioned  masses  of  vegetable  tissue,  seeds  of  fruits, 
pieces  of  bone,  enteroliths,  masses  of  fats,  and  soaps  of  high 
melting  point.  Olive  oil  won  its  undeserved  reputation  as 
a  means  of  removing  gall-stones  from  the  fact  that  many 
concretions  of  soaps,  superficially  resembling  gall-stones  are 
frequently  passed  after  ingestion  of  a  considerable  quantity 
of  this  oil. 

Gall-sand. — The  sand-like  concretions  found  so  plenti- 
fully in  some  stools  are  probably  not  from  the  gall-bladder. 
Genuine  gall-sand  would  be  likely  to  disappear  in  the 
bowel,  but  its  failure  to  do  so  would  not  explain  the  large 
quantities  of  it  in  the  stools  (Nauyn). 

Pancreatic  stones  are  rarely  found  in  the  stools,  and,  if 
found,  would  probably  occur  singly.  They  are  white  and 
consist  chiefly  of  calcium  carbonate. 

Enteroliths.— By  enterolith  is  meant  an  incrustation  of 
organic  salts  around  a  body  which  serves  as  a  nucleus, 
usually  a  hard  particle  of  food  or  a  lump  of  hardened  feces. 


78  EXAMINATION   OF   THE   FECES 

They  are  seldom  passed  in  the  stools.  Their  chief  impor- 
tance is  in  connection  with  appendicitis  (Emerson). 

Intestinal  Sand. — This  condition  is  frequently  reported, 
mostly  in  nervous  patients.  Intestinal  sand  in  small  gran- 
ules about  the  size  of  ordinary  sand  sometimes  appears  in 
the  stools  in  considerable  quantities,  even  half  an  ounce  or 
more.  The  passage  of  these  granules  may  be  an  incident 
of  a  nervous  period,  and  be  preceded  by  much  pain,  as  in 
the  paroxysms  of  mucous  colic.  Many  of  these  reported 
cases,  on  investigation,  have  proved  to  be  instances  of 
pseudo  sand,  seeds  of  berries,  granules  from  the  seed  case 
of  pears,  concretions  of  altered  blood  pigment  or  bile 
pigment,  or  concretions  of  medicines,  as  salol.  In  other 
instances  the  sand  may  be  real,  i.e.,  quartz  swallowed  with 
the  food. 

Meyer  and  Cook  cite  a  case  in  which  the  granules  proved 
to  be  masses  containing  resin  and  tannin,  which  came  from 
the  milk  cells  of  the  banana,  which  the  action  of  the  diges- 
tive juices  had  given  a  stony  hardness. 

Eichorst  describes  a  condition  which  he  calls  "gravel- 
forming  enteritis,"  explaining  it  as  a  secretory  neurosis. 

Chemical  analysis  of  true  intestinal  sand  has  shown  that 
it  contains  phosphates  and  carbonates,  especially  of  calcium, 
but  also  of  magnesium,  iron,  etc.;  while  in  some  of  the 
granules  calcium  sulphate  predominates.  Practically  all 
of  them,  however,  contain  some  organic  matter,  many 
bacteria,  fat,  cholesterin,  and  urobilin  (Emerson). 

Emerson  reports  two  cases  of  real  intestinal  sand.  In 
one,  a  young  boy  ill  with  an  indefinite  nervous  disorder, 
such  large  amounts  of  fine  granules  were  occasionally  passed 
that  the  sand  was  the  most  conspicuous  constituent  of  the 
stool.  The  other  patient,  a  young  woman  with  an  intes- 
tinal neurosis,  passed  many  granules,  which  seemed  to  be 
plugs  of  cells  impregnated  with  carbonates.  The  nature 
of  the  dead  cells  could  not  be  determined. 

This  interesting  condition  lacks  much  of  complete  eluci- 
dation, and  is  a  worthy  field  for  exhaustive  study. 


INTESTINAL   PARASITES  79 

Tumor  Fragments. — Tumor  fragments  or  the  broken- 
down  remains  of  polyps  or  intestinal  growths  may  appear 
in  the  stools,  having  their  origin  in  the  rectum,  colon,  or 
even  higher  up.  They  are  so  altered  in  their  passage  by  the 
intestinal  contents  that  they  ^re  extremely  hard  to  recog- 
nize; and  require  the  scrutiny  of  one  trained  in  such  in- 
vestigation to  identify  them  satisfactorily. 

INTESTINAL  PARASITES 

Ameba  Dysenteriae. — This  pathogenic  protozoon,  form- 
erly called  Amoeba  coli,  is  now  generally  admitted  to  be  the 
cause  of  amebic  dysentery,  a  colitis  characterized  by  a 
chronic  course,  frequent  and  bloody  stools,  a  tendency  to 
relapse,  and  frequent  association  with  abscess  of  the  liver. 


■t 


\'  /' 


/ 


Fig.  5. — Amoeba  coli.     (Hemmeter.) 

Craig  and  other  investigators  in  the  field  of  tropical 
medicine  have  identified  a  number  of  different  amebae, 
some  of  which  they  claim  to  be  harmless.  Musgrave,  how- 
ever, doubts  that  there  are  any  non-pathogenic  forms  of 
ameba,  or  at  least,  that  they  may  not  become  pathogenic. 


8o  EXAMINATION    OF    THE    FECES 

These  protozoa  are  found  with  amebic  dysentery.  Most 
of  them  are  in  the  floors  of  ulcers  which  undermine  the 
mucosa  of  the  colon  and  ileum,  and  in  the  burrowing 
tracts  which  radiate  from  these  ulcers  and  undermine  the 
mucosa.  They  are  also  found  in  the  contents  and  walls  of 
the  liver  abscesses,  which  complicate  this  disease,  and  in  the 
sputum,  if  the  abscesses  have  ruptured  into  the  lungs. 

The  ameba  dysenteriae  is  a  rhizopod,  varying  in  diameter 
from  8  to  50  microns.  It  has  a  clear  hyaline  ectosarc,  seen 
best  in  the  pseudopods,  a  finely  granular  endosarc,  usually 


Fig.  6. — E.  coli.     X  1,200.     Cyst  showing  6  nuclei.     (There  are  8  in  the  cyst, 
but  2  are  out  of  focus.)     (Craig.) 

containing  some  of  the  parasite's  ingesta  (red  blood-cells, 
leucocytes,  bacteria,  epithelial  cells,  and  minute  particles 
of  food),  and  often  one  or  more  vacuoles,  which  do  not 
pulsate.  Its  spherical  nucleus,  about  6  microns  in  diameter, 
is  sometimes,  especially  when  the  ectosarc  contains  little 
foreign  matter,  clearly  seen,  but  as  a  rule  not  visible  in  the 
living  parasite.  To  demonstrate  the  nucleus,  one  kills  the 
organism  with  corrosive  sublimate,  or  stains  it  by  appro- 
priate methods  (Emerson). 

To  obtain  a  specimen  for  examination,  little  flakes  of 
mucus  or  pus  should  be  selected,  or  the  mucus  may  be 
secured  by  passing  a  soft  catheter,  or  through  a  speculum. 
Preferably  a  saline  cathartic  should  be  previously  ad- 
ministered, and  the  fluid  portion  of  the  stool  examined 
while  warm.     The  last  precaution  is  quite  necessary,  and 


INTESTINAL   PARASITES  8 1 

various  devices  have  been  suggested  to  keep  the  stool 
warm.  A  most  convenient  method  is  to  employ  two  tin 
buckets,  one  holding  a  pint,  the  other  a  quart  or  half 
gallon.  The  patient  may  use  the  small  bucket  for  the 
stool,  which  may  be  passed  either  in  the  office  or  a  con- 
venient toilet.  The  larger  bucket  is  partly  filled  with  warm 
water,  and  the  small  one  placed  in  this  water  until  the 
specimen  is  examined.  The  slide  should  also  be  warmed, 
as  the  amebae  are  not  motile  when  cold. 


Fig.  7. — E.  Coli.     X  1,200.     Vegetative  form  showing  character  of  nucleus. 

{Craig.) 

The  organisms  in  different  cases  of  amebic  dysentery  do 
not  all  look  alike,  and  there  is  sometimes  so  much  difference 
that  some  observers  have  divided  them  up  into  quite  a 
number  of  varieties.  The  observer  must  endeavor  to 
distinguish  resting  amebag  from  degenerated  or  swollen 
epithelial  cells,  and  for  this  reason,  only  those  organisms 
should  be  called  amebse  which  unmistakably  project  a 
pseudopod,  and  which  are  to  some  extent  motile.  Others 
should  be  discarded. 

The  ameba  dysenteriae  has  been  found  in  various  diar- 
rheal conditions,  and  the  physician  should  be  mindful  of 
this.     Since  they  were  first  described  by  Losch,  they  have 

6 


82  EXAMINATION   OF   THE   FECES 

been  found  in  the  stools  during  typhoid  fever,  in  acute 
and  chronic  enteritis,  colitis  and  proctitis,  in  pellagra,  and 
even  in  the  stools  of  apparently  healthy  individuals,  who 
suffered  no  intestinal  disturbance. 

Allan,  of  Charlotte,  has  so  frequently  found  the  ameba  in 
the  stools  of  pellagrins,  that  he  has  argued  a  certain  relation 
between  the  two  conditions.  While  he  has  not  proved  his 
contention,  it  must  be  admitted  that  many  pellagrins  suffer 
from  amebic  dysentery,  and  that  many  cases  of  amebiasis 
also  suffer  from  pellagra. 

Schaudinn  and  Craig  have  positively  separated  the  Enta- 
meba  coli  from  the  Entameba  histolytica,  the  former  the  so- 
called  harmless  variety,  the  latter  the  pathogenic  variety 
causing  dysentery.     The  problem  of  non-pathogenic  amebae 


Fig.  8. — Balantidium  coli. 

a,  Nucleus;  b,  vacuoles;  c,  cytostome,  with  pit  and  peristome;  d,  ingested  material. 

(Tyson  after  Leuckart.) 

is  of  interest  to  the  zoologist,  but  the  physician  can  more 
safely  consider  every  ameba  he  finds  in  the  stools  as  pos- 
sibly pathogenic  and  possessing  present  or  future  poten- 
tialities for  harm.  Musgrave  examined  300  persons  in 
Manila,  of  whom  10 1  had  ameb^.  Of  these  sixty-one  had 
dysentery,  and  forty  had  no  signs  of  the  disease.  During 
the  next  five  months,  however,  every  one  of  these  forty 
developed  a  definite  dysentery. 

Balantidium  Coll.- — -This  parasite  of  the  colon  and  cecum 
of  the  hog  is  of  importance,  as  humans  are  not  infrequently 


EXAMINATION    OF    THE    FECES 


83 


20.    30.      -40.     50.     60.      70.      80.     00. 


10.     120.    130.    140.     ISO.     I60.    I70.    ISO.     190.    200. 


Fig.  9. — Parasitic  bodies,  ova,  and  lar 

only. 

1.  Larva  strongyloides  intestinab"s. 

2.  Ovum  of  fasciola  hepatica. 

3.  Ovum  of  tEenia  nana. 

4.  Ovum  of  uncinaria  duodenalis. 

5.  Ovum  of  uncinaria  americana. 

6.  Ovum  of  taenia  saginata. 

7.  Ovum  of  taenia  solium. 

8.  Ovum  of  opisthorchis  sinensis. 


vffi  met  in  human  feces;  color  approximate 
{Tyson.) 

9.  Ovum  of  opisthorchis  felineus. 

10.  Ovum  of  cotylogonimus  heterophj^es. 

11.  Ovum  of  taenia  cucumerina. 

12.  Ovum  of  ascaris  lumbricoides. 

13.  Ovum  of  dicrocoelium  lanceatum. 

14.  Ovum  of  bothriocephalus  latus. 

15.  Ovum  of  trichiuris  trichiura. 

16.  Ovum  of  oxyuris  vermicularis. 


INTESTINAL   PARASITES  85 

infected  with  it.  The  body  is  oval-shaped,  the  anterior 
end  is  sHghtly  truncated,  with  a  short  peristome,  generally 
funnel-shaped,  and  opens  externally  near  the  anterior 
pole.  When  feeding  it  opens  out  and  broadens,  so  one  can 
see  it  is  a  mouth  which  leads  to  a  gullet,  and  not  a  simple 
furrow.  The  interior  structure  of  this  parasite  consists  of 
granular  substance,  and  it  contains  a  nucleus  and  con- 
tractile vacuoles.  Fat  and  starch  granules,  and  occasion- 
ally red  and  white  corpuscles  may  be  found  within  the 
granular  substance.  The  posterior  end  is  rounded,  contains 
the  anus,  and  particles  may  be  observed  to  pass  from  it. 
This  parasite  can  change  its  shape,  and  possesses  both  for- 
ward and  rotary  motion.  Human  infection  from  this  para- 
site probably  occurs  most  frequently  through  the  infusorium 
entering  its  host  in  the  encapsulated  state.  When  hog  feces 
are  dried  and  pulverized,  the  encysted  forms  are  scattered 
about  and  come  in  contact  with  food  and  drinking  water, 
and  in  this  way  the  infection  easily  follows. 

The  pathogenicity  of  these  parasites  to  the  human  has 
been  questioned  by  some,  but  it  is  now  fairly  well  conceded 
that  they  may  set  up  a  severe  catarrh,  which  may  even  be 
fatal.  Henschen  claims  that  they  may  cause  a  catarrh, 
which  continues  after  they  die  out.  Musgrave,  Strong  and 
Klimenko  have  furnished  the  most  of  our  present  informa- 
tion concerning  them. 

Ascaris  Lumbricoides. — This,  the  ordinary  "round 
worm,  "  is  very  common,  and,  according  to  Garrison,  occurs 
in  about  0.4  of  all  cases.  The  female  is  about  20  to  40  cm. 
long,  5  mm.  thick,  with  a  straight  and  conical  tail.  The 
posterior  end  of  this  parasite  is  bent  ventrally  into  a  hook, 
and  terminates  into  two  spicules.  The  mouth  of  both  male 
and  female  is  surrounded  by  three  papillae,  and  the  color 
is  gray  or  a  dirty  reddish-brown.  Though  it  is  an  in- 
habitant of  the  small  intestine,  and  is  therefore  most  often 
seen  in  the  stools,  it  sometimes  appears  in  the  vomitus, 
generally   to   the   great   alarm   and   consternation   of  the 


86 


EXAMINATION    OF    THE    FECES 


Fig.   io. — Ascaris  lumbricoides :  to  left,  male  in  lateral  aspect;  to  right,  female, 
ventral  aspect,  natural  size.     {Tyson  after  Railliet.) 


INTESTINAL   PARASITES 


87 


patient.     In  fact,  there  is  nothing  more  repulsive  to  the 
average  individual  than  the  vomiting  of  worms. 

The  eggs  of  this  worm  are-  also  found  in  the^stools  in  large 


o. 


Fig.  II. — Oxyuris  vermicularis :  to  left,  female;  to  right,  male  (considerably 

enlarged) . 
A,  Anus;  0,  mouth;  v,  vulva.     (Tyson  after  Braun.) 

numbers,  are  elliptical,  are  50  to  70  microns  long,  and  40  to 
5o^microns  wide.  They  have  an  unsegmented  protoplasm 
surrounded  by  a  thick  transparent  shell,  which  is  covered 


88  EXAMINATION    OF   THE   EECES 

by  a  thick,  uneven  and  lumpy  gelatinous  envelope,  usually 
bile-stained.  In  searching  for  this  worm  it  is  well  to  first 
give  santonin,  which  will  promote  both  their, death  and 
expulsion. 

Oxyuris  Vermicularis. — (Thread- worm ;  Pin-worm;  Seat- 
worm.) This  little  parasite  occiirs  in  the  rectum  and  colon, 
even  as  high  as  the  cecum,  where  it  may  invade  the  appendix 
and  even  reach  the  stomach.  They  have  been  known  to 
penetrate  through  the  uterus  and  tube  into  Douglas' 
cul-de-sac.  Some  abscesses  are  thought  to  have  been 
caused  by  their  boring  through  the  intestinal  walls.  They 
are  present  in  perhaps  0.8  per  cent,  of  adults. 

The  adult  male  is  from  3  to  5  mm.  long,  with  its  posterior 
end  bent  into  a  ventral  hook.  The  female  is  about  10  mm. 
long.  The  worms  are  white  in  color.  The  eggs  are  50 
microns  long  and  have  a  characteristic  symmetry.  The 
worm  leaves  the  rectum  to  lay  its  eggs  on  the  skin  surround- 
ing the  anus,  and  it  is  then  that  the  itching  occurs.  The 
eggs  when  deposited  already  contain  a  fairly  well-developed 
embryo.  These  eggs  are  seldom  found  in  the  stools,  except 
in  the  mucus  which  may  coat  the  stool  as  it  passes  through 
the  rectum.  The  eggs  will  not  be  found  by  a  cursory  ex- 
amination of  the  skin  around  the  anus,  but  it  will  be 
necessary  to  first  scrape  away  the  surface  epithelium. 
They  can  then  be  observed. 

Cestodes. — The  adult  parasites  live  in  the  small  intestine 
of  man;  the  larval  forms  may  be  found  in  the  muscles  and 
other  organs.  The  most  important  varieties  of  tapeworms 
found  in  human  beings  are  the  Taenia  solium,  Taenia  medio- 
canellata,  and  the  Bothriocephalas  latus. 

The  diagnosis  can  only  be  made  by  the  discovery  of  the 
segments  of  this  parasite  or  the  eggs  in  the  stools. 

The  tapeworm  has  a  scolex  or  head,  which  may  live  for 
years,  even  when  detached  from  the  rest  of  its  body,  an 
oblong  neck,  and  detachable  segments  (proglottides). 
These  segments  vary  in  size  and  shape  and  possess  the 
power  of  limited  motion.     The  worm  itself  is  flat  and  lacks 


INTESTINAL   PARASITES  89 

both  mouth  and  intestines.  It  grows  by  alternate  genera- 
tion through  germination  of  a  pear-shaped  primary  host, 
and  remains  united  to  the  latter  for  a  time  as  a  colony  of 
bandlike  shape.  Each  segment  forms  a  sexually  active 
individual.  The  proglottides  gradually  increase  in  size 
as  they  become  more  distant  from  the  head,  and  then 
diminish  again  toward  the  extremity.  This  worm  is  an 
hermaphrodite.  On  its  head  are  four  sucking  disks,  by 
which  it  attaches  itself  to  the  mucosa  of  the  intestines,  and 
by  means  of  pores  it  derives  its  nourishment  from  the 
chyme. 

The  older  and  better-developed  proglottides  contain 
many  fertile  eggs,  which  are  emptied  into  the  intestinal  canal 
and  appear  in  the  stools.  The  ovum  contains  an  embryo, 
which  requires  for  its  development  an  intermediary  host. 
After  reaching  the  stomach  the  envelop  is  dissolved  by  the 
gastric  juice.  The  embryo  is  set  free,  and  finds  its  way  by 
the  lymphatics  or  blood-vessels  to  some  place  (usually  the 
muscles),  where  it  settles.  It  here  surrounds  itself  with  a 
sac,  which  may  later  be  enveloped  by  a  calcareous  deposit. 
In  this  condition  it  is  called  a  cysticercus  or  measle.  When 
the  measle  reaches  the  stomach  of  a  new  host  it  opens,  and 
its  scole  enters  into  the  small  intestine,  where  it  develops 
into  a  full-grown  tapeworm. 

Taenia  Solium. — This  is  the  armed  or  pork  tapeworm, 
is  not  common  in  America,  but  is  rather  frequent  in  Europe 
and  Asia.  When  mature  it  may  reach  the  astonishing 
length  of  10  or  12  feet.  The  head  of  this  worm  is  smaller 
than  the  head  of  a  pin,  spherical,  and  provided  with  four 
sucking  disks,  in  the  middle  of  which  is  the  rostellum  and  a 
double  row  of  hooklets,  from  twenty-four  to  twenty-six  in 
number,  and  from  these  bristling  hooklets  it  derives  its 
name.  The  neck  is  narrow  and  slender  and  nearly  an  inch 
long.  The  body  is  divided  into  segments,  possessing  both 
male  and  female  generative  organs,  and  at  about  the  four 
hundred  and  fiftieth  they  become  mature  and  contain  ripe 
ova.     The  segments  are  about  i  cm.  long  and  about  7  or 


QO  EXAMINATION    OP   THE   FECES 

8  mm.  wide.  The  worm  attains  its  full  growth  in  three  to 
four  months,  about  which  time  the  segments  begin  to  shed 
and  appear  in  the  stools.  The  uterus  forms  a  straight 
median  tube  in  each  segment,  giving  off  five  to  seven 
branches  on  each  side.  The  eggs  are  rounded  and  covered 
with  a  thick  shell. 

Occasionally  the  cysticerci  (measles)  are  found  in  man, 
either  in  the  muscles,  brain,  or  skin. 


Fig.  12. — Head  and  neck,  and  ovum  X300,  of  tenia  solium.     Embryophore 
surrounded  by  vitellus.     {Tyson  after  Gould.) 


When  found  in  the  muscles,  they  produce  pain,  numb- 
ness, weakness,  and  symptoms  resembling  peripheral  neu- 
ritis. In  the  ventricles  of  the  brain,  they  cause  irritative 
symptoms,  and  may  produce  death. 

Taenia  Saginata. — This  is  the  unarmed  beef  tapeworm, 
and  is  seen  in  America  as  well  as  Europe  and  Asia.  It  is 
longer,  thicker,  and  wider  than  the  armed  variety,  and  may 
grow  as  long  as  20  feet.  The  head  measures  over  2  mm.  in 
breadth,  has  four  large  sucking  disks,  but  no  hooklets. 

The  ripe  segments  are  about  18  mm.  in  length,  and  8  or 
10  in  breadth.  The  uterus  consists  of  a  median  stem,  with 
from  twenty  to  thirty-five  lateral  branches.  The  ova  are 
large,  and  the  shell  thicker  than  those  of  the  armed  worm, 
but  the  difference  is  not  striking  enough  to  make  it  easy  to 
discriminate  between  the  two.     The  measles  occur  in  beef, 


INTESTINAL   PARASITES 


91 


being  smaller  than  the  Taenia  solium.  This  parasite  is 
acquired  in  man  by  the  eating  of  raw  beef. 

Bothriocephalus  Latus. — This  tapeworm  is  found  in 
certain  districts  bordering  on  the  Baltic  Sea,  in  Holland, 
Switzerland,  and  Japan.  The  very  few  cases  found  in  the 
United  States  are  believed  to  have  been  imported. 

This  tapeworm  is  the  longest  of  the  varieties,  measuring 
from  25  to  30  feet,  or  even  more  in  rare  instances.     The 


Fig.  13. — Head  and  neck  of  taenia 
saginata:  A,  retracted:  B,  -extended. 
{Tyson  after  Gould.) 


Fig.  14. — Bothriocephalus  latus. 
{Tyson  after  Leuckart.) 


head  is  elongated,  almond-shaped,  is  about  2  mm.  long  and 
I  mm.  broad.  It  has  no  hooklets.  The  neck  is  narrow 
and^^short,  about  2  cm.  long,  and  passes  at  once  into  the 
body  segment.  The  body  is  thin  and  flat.  The  full- 
grown  proglottides  are  nearly  square,  and  show  the  sexual 
organs  in  the  center.  The  uterus  shows  a  median  dark 
line,  with  four  to  six  lateral  branches,  resembling  a  star  or 


92 


EXAMINATION    OF    THE   FECES 


rosette.  The  eggs  are  oval  and  round,  with  a  thin  mem- 
brane and  a  lid.  The  larvse  of  this  parasite  develop  in  the 
peritoneum  and  muscles  of  pike  especially,  and  of  other 


Fig.  15. — Taenia  nana:  X  10.     {Tyson  after  Gould.) 

fish,  as  perch  or  trout.     Infection  occurs  from  eating  raw  or 
insufficiently  cooked  fish. 

Echinococci  are  the  larvse  of  the  Taenia  echinococcus  of 
the  dog.  This  is  a  tiny  cestode  4  or  5  mm.  long,  consisting 
of  three  or  four  segments,  of  which  the  terminal  one  alone 


Fig.  16. — Tasnja  echinococcus.     {Tyson  ajter  Coplin  and  Bevan.) 
a,  Adult;  b,  head  from  echinococcus  cyst.     On  left  a  detached  hooklet,  as  seen  in 

fluid  from  cyst. 

is  mature.     The  head  is  small,  provided  with  four  sucking 
disks,  and  a  rostellum  with  a  double  row  of  hooklets. 

When  these  parasites  are  taken  into  the  body  with  food 
or  in  any  other  manner,  cysts  develop  in  various  parts  of  the 


INTESTINAL   PARASITES  93 

human  organism,  as  in  the  Hver  or  muscles.  These  cysts 
contain  scolices,  the  head  of  the  taenia  presenting  four 
sucking  disks  and  a  circle  of  hooklets.  These  cysts  have 
been  passed  from  the  rectum.  This  malady  is  common  in 
Iceland,  rather  frequent  in  Europe,  and  rare  in  the  United 
States.     It  is  commonly  written  of  as  Echinococcus  Disease. 

Tricocephalus  Dispar  (Whip -worm). — This  parasite  is 
found  in  the  cecum  and  large  intestine  of  man.  It  measures 
from  4  to  5  cm.  long,  the  male  being  somewhat  smaller  than 
the  female.  It  is  easily  recognized  by  the  peculiar  differ- 
ences between  the  anterior  and  posterior  portions.  The 
anterior  forms  three-fifths  of  the  body,  is  thin  and  hair-like, 
while  the  tail  end  of  the  female  is  more  conical  and  thicker, 
terminating  in  a  blunt  extremity.  The  tail  end  of  the  male 
is  rolled  somewhat  like  a  spring. 

The  number  of  these  worms  is  variable,  as  many  as  a 
thousand  having  been  counted,  while  sometimes  only  ten 
or  fifteen  are  found.  In  some  parts  of  Europe  they  are 
very  common,  but  are  rare  in  the  United  States.  Occa- 
sionally profound  symptoms  of  diarrhea  and  anemia  have 
accompanied  their  presence,  but  often  no  symptoms  appear, 
though  many  may  be  present. 

Trichina  Spiralis  (Trichiniasis). — The  trichina  in  its 
adult  form  lives  in  the  small  intestine.  The  embryos 
pass  from  the  intestines,  and  reach  the  voluntary  muscles, 
where  they  become  encapsulated  larvae. 

The  history  of  trichiniasis  is  interesting.  In  1822 
Tiedemann  described  the  ovoid  cysts  in  the  human  muscle. 
Later  Owen  named  it.  In  1845  Leidy  described  it  in  the 
pig.  In  i860  Zenker  discovered  in  a  young  girl  both  the 
intestinal  and  muscle  forms,  and  satisfactorily  estab- 
lished their  connection  with  the  specific  symptoms. 

The  proper  understanding  of  this  parasite  is  most 
important.  Man  is  infected  with  it  by  eating  the  raw  or 
partly  cooked  flesh  of  trichinous  hogs,  which  contain  the 
encapsulated  trichinae.  These  capsules  are  digested  in  the 
stomach,  and  the  trichinae  set  free.     They  then  pass  into 


94 


EXAMINATION    OF    THE   FECES 


Fig.  17. — Trichinella  spiralis.     {Tyson  after  Braun.) 
a,  Gravid  female  "intestinal  trichiura;"  C,  embryos;  G,  vulva;  Ov,  ovary;, 
6,  adult  male,  "intestinal  trichiura;"  T,  testicles;  C,  young  larva;  (^,  larva  in 
musculature;  e,  encapsulated  larva  in  muscle. 


INTESTINAL   PARASITES  95 

the  small  intestine,  and  about  the  third  day  become 
sexually  mature.  By  the  sixth  or  seventh  day  the  embryos 
are  fully  developed.  The  young  produced  by  each  female 
trichina  have  been  estimated  at  several  hundred.  The 
female  worm  penetrates  the  intestinal  wall,  and  the  embryos 
are  probably  discharged  directly  into  the  lymph-spaces, 
and  thence  into  the  venous  system,  whence  they  reach  the 
muscles;  and  in  about  two  weeks  they  develop  into  the 
full-grown  muscle  form.  A  myositis  is  then  caused  by 
their  irritation,  and  they  may  become  encapsulated.  The 
trichinae  may  live  in  these  cysts  for  many  years,  and  they 
may  be  surrounded  by  a  calcareous  deposit.  In  the  hog  the 
capsule  does  not  readily  become  calcified,  so  that  the  trichi- 
nae are  not  as  readily  visible  as  in  man ;  besides,  an  apparently 
healthy  animal  may  be  suffering  from  the  presence  of  the 
trichina. 

The  intestinal  trichinae  are  visible  to  the  naked  eye — 
white  glistening  worms  4  or  5  mm.  long.  The  male  is 
half  this  size,  with  two  little  projections  from  the  hind  end. 
The  caudal  extremity  is  thicker  than  the  head.  The  muscle 
trichina  is  only  about  0.6  mm.  long  and  coiled  in  the 
capsule,  with  a  pointed  head  and  rounded  tail.  Theodore 
Janeway  and  one  or  two  others  have  demonstrated  the 
Trichinella  spiralis  in  the  human  blood,  and  Packard  re- 
ports finding  an  embryo  in  the  blood  of  a  patient,  and  a  short 
time  later  larger  embryos  were  'found  in  the  muscle,  not 
yet  encysted. 

Strongyloides  Intestinalis  (Anguillula  stercoralis  et  in- 
testinalis;  Leptodera  stercoralis  et  intestinalis;  Rhab- 
domena  strongyloides). — This  is  a  small  nematode  worm 
found  in  the  feces.  It  is  frequent  in  the  tropics  and  warm 
countries  in  cases  of  endemic  diarrhea,  and  is  occasionally 
found  in  this  country.  Thayer  reports  three  cases  from 
Osier's  clinic. 

The  adult  female  resembles  a  filaria,  and  measures  about 
2  mm.  long  and  35  microns  wide.  The  body  increases 
slightly  and  gradually  in  size  from  the  head  to  the  posterior 


96 


EXAMINATION    OF   THE   FECES 


quarter,  and  then  terminates  suddenly  in  a  short  tail. 
The  male  is  slightly  smaller.  These  worms  are  abundant 
in  the  duodenum,  fewer  in  the  jejunum.  The  adult  worms 
are  seldom  found  in  the  stools. 


Fig.  i8. — Strongyloides  intestinalis;  on  the  left,  a  gravid  female  from  human 
intestine  (natural  size  2.5  mm.).  In  the  middle,  a  rhabditiform  larva  from  fresh 
fecal  matter,  X  120;  to  the  right,  a  filariform  larva  from  culture,  X  120.  {Tyson 
after  Braun.) 

The  rhabditiform  larvae  of  this  parasite  found  in  the 
stools  are  quite  active,  and  the  best  way  to  find  them  is  to 
make  a  depression  in  the  fecal  mass,  fill  it  with  water, 
place  the  stool  then  in  a  thermostat  or  thermos  bottle,_and 


INTESTINAL    PARASITES  97 

examine  the  water  next  day  for  the  eel-hke  worms.  The  eggs 
do  occur,  but  rarely,  and  are  extremely  hard  to  distinguish 
from  the  Uncinaria  duodenalis. 

Trematodes  (Fluke  Worms;  Distomiasis). — Flukes  are 
found  in  the  lungs,  liver,  small  intestine,  and  in  the  blood. 


^ 


/ 

/  . 
/    ^ 


Fig.  19. — Fasciolopsis  buski.     {Tyson  after  Braun.) 

a,  Ora  sucker;  h,  acetabulum;  c,  cirrus  pouch;  d,  vitelline  glands;  e,  "shell  gland;" 

/  and  g,  posterior  and  anterior  testicles;  h,  ovary;  i,  cecum;  k,  uterus. 

They  are  solid  worms  of  a  leaf  or  tongue  shape,  possessing 
a  clinging  apparatus  in  the  form  of  oral  and  ventral  sucking 
cups,  which  vary  in  number.  Sometimes  they  have  a 
hook-like  projection.  The  intestinal  canal  of  this  parasite 
7 


98 


EXAMINATION   OF    THE   EECES 


is  without  an  anus  and  split  like  a  fork.     They  are  generally 
hermaphroditic. 

Flukes  have  been  reported  and  carefully  studied  in  the  far 
East,  especially  in  China,  Japan,  and  India.  Houghton 
reported  that  8  per  cent,  of  all  male  patients  admitted  to  the 


Fig.  20. — Showing  the  sexual  glands  of  fasciola  hepatica;  5X1.     {Tyson  after 

Braun.) 
O,  Oral  sucker;  D,  intestinal  ceca;  Do,  vitelline  glands;  Dr,  ovary;  Ov,  uterine 
canal;  T,  testicles;  Sq,  "shell  gland;"  V,  transverse  vitelline  duct;  Gp,  genital 
pore;  S,  ventral  sucker. 


Wuhu  General  Hospital,  Anhui,  during  one  year  were  in- 
fected. Nearly  all  these  patients  were  farmers  and  boatmen. 
Wellrmarked  cases  of  this  infection  show  enlarged  liver 
and  spleen,  cachexia,  eosinophilia,  ascites,  greatly  ex- 
aggerated knee-jerks,  and  bloody  stools.     The  leucocyte 


INTESTINAL   PARASITES 


99 


count  is  not  increased,  but  varies  from  2000  to  8500  per 
cubic  millimeter. 

The  ova  may  be  found  in  the  blood,  but  they  are  noted 
mostly  in  the  stools,  although  they  are  found  with  some 


Fig.  21. — Copula tory  bursa  of  Necator  americanus,  showing  the  deep  cleft 
dividing  the  branches  of  the  dorsal  ray  and  the  bipartite  tips  of  the  branches; 
also  showing  the  fusion  of  the  spicules  to  terminate  in  a  single  barb.  Scale 
i/io  mm.     {Stitt.) 

lb,  Branches  of  dorsal  ray  magnified;  2a,  the  buccal  capsule  of  N.  americanus; 
2b,  the  same  magnified;  3a,  copulatory  bursa  of  Anchylostoma  duodenale,  showing 
shallow  clefts  between  branches  of  the  dorsal  ray  and  the  tridigitate  terminations, 
spicules  hair-like;  36,  the  dorsal  ray  magnified;  4a,  the  buccal  capsule  of  A. 
duodenale,  showing  the  much  larger  mouth  opening  and  the  prominent  hook-like 
ventral  teeth;  ^h,  the  same  magnified;  50,  egg  of  N.  americanus;  56,  egg  of  A. 
duodenale;  6a,  rhabditiform  larva  of  strongyloides  as  seen  in  fresh  feces.  6b, 
rhabditiform  larva  of  hookworm  in  feces  eight  to  twelve  hours  after  passage  of 
stool. 


difficulty.  In  size  they  resemble  the  ova  of  the  Ascaris 
lumbricoides,  for  which,  under  the  low  power,  they  may 
be  easily  mistaken.  The  latter  ova,  however,  are  much 
more   refractile,    and,    since    their    envelops    are    sticky, 


lOO  EXAMINATION    OF   THE    FECES 

gather  debris  in  the  stool  and  leucocytes  in  the  blood.  In 
the  fresh  stool  the  embryo  in  the  egg  is  quiescent  and  shaped 
like  a  melon  seed;  later  there  is  motion  of  the  cilia.  The 
free-swimming  miracidium  is  seen  only  after  the  stool  has 
stood  about  ten  hours.  It  can  be  kept  alive  in  water  for 
four  or  five  days. 

Among  others  in  the  trematode  class  may  be  mentioned 
the  Fasciolopsis  buski,  found  so  far  only  in  the  far  East ;  the 
Distomum  lanceolatum,  a  very  rare  parasite  which  hatches 


Fig.  22.— Tail,  with  expanded  bursa,  of  male  Necator  americanus.     {Tyson  and 

Fussell.) 

only  on  the  intestine  of  some  intermediary  host,  perhaps  the 
slug,  and  has  been  found  in  the  intestines  and  biliary  ducts 
of  European  and  American  domestic  animals;  the  Fasciola 
hepatica,  or  liver  fluke,  a  widely  spread  parasite  inhabiting 
the  bile  ducts  of  some  herbivorous  mammals.  These  are 
so  frequently  found,  that  their  history  and  detailed  descrip- 
tion may  be  left  to  special  works  on  parasites. 

Uncinaria  Duodenalis;  Uncinaria  Americana;  Hook- 
worm. History. — The  history  of  our  knowledge  of  this 
important  parasite  is  most  interesting.  As  has  so  often 
been  found,  where  parasites  of  this  class  are  concerned, 
members  of  the  genus  were  first  discovered  in  the  lower 
animals,  the  worm  being  by  no  means  confined  to  man.  A 
German  clergyman,  by  the  name  of  Goeze,  in  1792  was  the 
first  to  describe  it,  his  observations  having  been  made  on 
the    particular    species    of    hookworm    that    inhabits    the 


UNCINARIA   AMERICANA  lOI 

intestinal  tract  of  the  badger.  Seven  years  later  Froelich 
discovered  a  somewhat  similar  worm  in  the  intestinal  tract 
of  the  fox,  and  gave  to  the  parasite  our  present  appellation 
"hookworm,"  being  the  literal  translation  of  the  German 
"Haakenworm."  He  it  was  who  also  originated  the  name, 
"Uncinaria,"  this  being  the  zoological  name  for  the  genus 
in  which  this  worm  is  still  included  by  most  writers. 

This  worm  was  first  observed  as  a  human  parasite  in  1838 
by  an  Italian  named  Dubini,  and  six  years  later  he  de- 
scribed it  by  the  name  of  Anchylostoma  duodenale.  Ten 
years  later  both  Bilharz  and  Griesinger  proved  that  the 
profound  anemia  so  common  in  northern  Africa,  and  known 
as  "Egyptian  chlorosis"  was  certainly  produced  by  this 
parasite.  In  1878  it  was  shown  that  laborers  working  on 
the  St.  Gotthardt  tunnel  were  almost  all  infected  with  the 
worm,  and  Perrocito,  who  discovered  this,  also  demon- 
strated that  the  disease  prevailed  in  the  mountains  of 
northern  Italy,  and  was  called  "Mountain  anemia"  or 
"Mine  anemia." 

Following  these  observations,  investigators  from  different 
parts  of  the  world  began  to  report  this  worm  with  great 
frequency,  and  at  present  it  is  known  to  be  prevalent  in 
every  part  of  the  globe  where  climate  conditions  favor  its 
development. 

Writings  of  many  American  physicians  show  beyond 
question  that  hookworm  disease,  the  victims  of  which  were 
called  "dirt  eaters,"  has  prevailed  in  this  country  for  at 
least  a  hundred  years,  and  no  doubt  it  has  existed  ever 
since  the  importation  of  slaves  began.  Notwithstanding 
this,  the  true  nature  and  cause  of  the  trouble  was  not 
recognized  until  recent  years,  and  the  first  case  of  hook- 
worm disease,  where  the  diagnosis  was  definitely  estab- 
lished, was  reported  by  Blickhahn  in  1893.  In  1902  Stiles 
showed  that  the  parasite  as  found  in  America  differed  in  some 
minor  particulars  from  those  found  in  Egypt  and  southern 
Europe,  and  he  gave  to  what  was  supposed  to  be  our  new- 
world  species  of  the  worm  the  name  of  Uncinaria  Ameri- 


I02  EXAMINATION   OF    THE   FECES 

cana.  At  that  time  it  was  also  sometimes  called  ' '  Necator 
Americanus,"  or  the  American  murderer. 

The  hookworm  belongs  to  the  order  of  nematodes  or 
round  worms,  being  related  to  and  much  resembling  the 
small  "pin  worm"  which  is  well  known.  On  careful 
examination,  however,  the  two  present  marked  differences, 
which  may  be  detected  with  the  naked  eye  by  one  well 
acquainted  with  their  peculiarities.  Microscopically  they 
differ  still  more.  Like  the  pin-worm,  the  hookworm  is 
small,  being  in  the  case  of  the  female  about  1/2  inch  long, 
and  about  the  width  of  an  ordinary  hat  pin;  the  male  is 
slightly  smaller  than  the  female.  In  the  fresh  state  the 
worm  is  often  of  a  pinkish  gray;  after  death,  however,  it 
assumes  a  dull  grayish  tint.  Unlike  the  pin- worm,  this 
parasite  is  not  found,  except  in  rare  instances,  in  the  feces, 
and  its  presence  in  the  stools  plays  no  part  in  making  the 
diagnosis  of  the  disease. 

Like  many  other  diseases  or  infections,  while  the  symp- 
toms may  point  with  almost  a  certainty  to  the  presence  of 
these  worms  in  an  individual,  the  only  way  to  be  absolutely 
sure  is  to  examine  the  feces  for  the  eggs.  This  examina- 
tion is  a  simple  one,  requiring  only  a  glass  slide  upon  which 
to  spread  the  specimen  of  feces  and  a  low-power  microscope. 
As  the  eggs  are,  as  a  rule,  very  numerous,  the  diagnosis 
can  usually  be  made  quickly,  although  in  some  instances, 
where  the  number  of  worms  is  small,  the  finding  requires  a 
more  careful  study.  The  eggs  are  found  in  the  stools  either 
unsegmented  or  during  the  early  stages  of  segmentation. 
They  have  a  clear  thin  shell.  While  the  yolk  will  show 
all  stages  of  segmentation,  it  is  rare  to  find  eggs  with 
an  undivided  yolk,  those  divided  into  four,  eight,  sixteen, 
or  more  segments  being  the  most  common.  The  eggs 
should  be  searched  for  in  the  feces  by  mixing  a  small  amount 
with  a  drop  of  water  on  a  slide.  The  older  the  feces  and 
the  warmer  the  weather,  the  more  advanced  will  be  the 
segmentation. 

To  find  eggs  in  stools,  where  they  are  not  numerous,  it  is 


EXAMINATION   FOR   UNCINARIA  IO3 

well  to  follow  the  suggestions  of  Dock  and  Bass.  The  stool 
is  diluted  with  about  ten  volumes  of  water,  is  strained 
through  two  or  three  layers  of  gauze  in  a  funnel,  and  is  then 
centrifugaUzed  until  the  sediment  is  thrown  down.  The 
supernatant  fluid  is  poured  off,  more  water  is  added,  the 
tube  is  well  shaken,  and  the  stool  again  centrifugaUzed. 
Since  hookworm  eggs  stick  to  glass  in  a  pecuHar  way,  a  drop 
of  the  sediment  is  put  on  a  glass  sHde,  and  the  sHde  is  gently 
immersed  in  water,  which  will  wash  off  much  of  the  sedi- 
ment, while  the  eggs  will  stick  to  the  glass.  Another  drop 
of  the  sediment  is  then  put  on  the  same  spot,  and  the 
immersion  repeated.  This  being  repeated  several  times, 
the  eggs  will  be  easily  observed,  if  any  are  present.  The 
disadvantage  of  this  procedure  lies  in  the  fact  that  other 
varieties  of  eggs,  which  might  be  in  the  specimen  are  lost. 
The  adult  hookworms  may  be  found  in  the  sedimented 
stool  after  a  small  dose  of  thymol  followed  by  oil.  The 
adults  are  usually  red  from  the  blood  with  which  they  are 
filled.  They  abound  in  the  duodenum,  ileum,  and  jejunum, 
sometimes  many  thousands  in  one  person,  though  in  most 
instances,  only  a  few  hundred.  While  they  do  not  multiply 
in  the  intestines,  they  may  live  there  for  years,  and  the 
clinical  symptoms  are  not  a  fair  criterion  as  to  the  number 
infesting  the  intestinal  tract  of  any  individual. 

Larvae  of  flies  are  sometimes  present  in  stools.  This  oc- 
curs when  the  patients  evacuate  their  bowels  in  exposed 
places,  where  the  flies  can  deposit  their  eggs  on  or  just 
inside  the  anal  orifice.  These  larvce  are  sometimes  passed 
in  astonishing  quantities,  generally  to  the  great  consterna- 
tion of  the  patient.  Their  identification  should  present 
no  special  difficulty,  and,  should  there  be  any  doubt,  if 
some  of  the  larv£e  together  with  a  small  amount  of  feces, 
are  kept  in  a  vessel  over  which  is  thrown  netting  or  cheese- 
cloth, so  that  air  may  freely  enter;  and  if  this  is  kept  in  a 
warm  place  for  several  days,  the  flies  will  hatch  out,  and 
their  particular  variety  be  known. 

Plant  Parasites. — Various  yeasts  are  often  present  in 


I04  EXAMINATION   OF   THE   FECES 

normal  stools,  though  moulds  are  rare.  Blastomycetes 
have  been  found  in  the  stools  of  patients  with  systemic 
infection  with  this  parasite.  The  Oidium  albicans  has 
occasionally  been  found  in  children.  Sarcinse  are  fre- 
quently found  in  cases  of  dilated  stomach,  especially  where 
the  hydrochloric  acid  is  deficient.  When  present  in  large 
numbers,  they  may  aggravate  a  diarrhea  by  the  products  of 
their  fermenting  processes. 

Microorganisms. — These  form  a  large  portion  of  the 
stool,  most  of  them  being  dead.  Almost  any  organism 
may  appear  accidentally  in  the  feces,  but  there  is  a  flora  of 
bacteria  so  constantly  found,  that  their  presence  may  be 
considered  normal.  Among  the  most  important  are  the 
Bacillus  coli,  Bacillus  lactis  aerogenes,  Bacillus  bifidus. 
Bacillus  aerogenes  capsulatus  (gas-forming),  and  Bacillus 
putrificus. 

The  Bacillus  coli  is  of  importance  in  reference  to  the 
indolic  type,  and  some  observers  are  disposed  to  accord  this 
bacillus  a  wide  range  of  activity  in  the  etiology  of  various 
diseases.  The  Bacillus  ^rogenes  capsulatus  is  concerned 
in  the  saccharobutyric  type  of  intestinal  putrefaction. 
The  Bacillus  lactis  aerogenes  causes  fermentation  of  milk 
and  the  production  of  lactic  acid.  These  lactic-acid- 
producing  bacilli  are  held  to  be  antagonistic  to  putrefactive 
changes  and  much  investigation  has  been  entered  into  under 
this  assumption.  To  even  partly  "sterilize"  the  intestinal 
tract,  however,  seems  rather  chimerical  to  most  individuals. 
The  Bacillus  bifidus  appears  to  be  a  normal  inhabitant  of 
the  nursing  infant,  disappearing  soon  after  the  child  is 
weaned.  When  it  persists,  its  presence  would  seem  to  be 
associated  with  certain  symptoms  of  intestinal  intoxication. 
Its  most  characteristic  shape  is  like  the  letter  Y,  hence  its 
name.  Involution  forms  are  most  common.  The  greatest 
interest  attached  to  this  organism  is  that  it  is  one  of  the 
few  intestinal  organisms  which  is  not  discolored  by  the 
Gram  method.     It  is  a  strict  an^robe. 

There  might  be  mentioned  also  the  Bacillus  pyocyaneus, 


MICROORGANISMS   IN   THE   FECES  I05 

Bacillus  tetani,  the  Staphylococcus  group,  and  many  of  the 
thermophilic  and  acidophilic  organisms,  but  a  detailed  de- 
scription would  be  superfluous  in  a  work  of  this  character. 
It  may  be  stated,  however,  that  the  present  opinion  is  that 
the  lower  bowel,  at  least,  is  not  a  favorable  habitat  for 
living  organisms,  and  that  most  of  them  found  in  the  stool 
are  dead. 

Tubercle  Bacilli. — In  searching  for  these  it  is  not  neces- 
sary to  digest  a  solid  stool.  Mucous  masses  should  be 
selected,  especially  the  blood-stained  or  puriilent  particles, 
and  these  treated  as  sputum.  In  intestinal  tuberculosis, 
the  bacilli  are  often  present;  still  in  many  cases  of  un- 
doubted presence  of  this  disease  none  are  found.  Probably 
many  are  destroyed  before  their  exit  with  the  stools, 
especially  when  there  is  much  fermentation  going  on  in  the 
intestinal  tract.  When  found,  their  origin  from  swallowed 
sputum  must  be  considered,  and  the  diagnosis  of  tuberculo- 
sis in  children  has  been  made  this  way. 

Page's  method,  as  cited  by  Emerson,  is  to  suspend  a 
piece  of  the  solid  stool  half  the  size  of  a  pea  in  1.5  c.c.  of 
distilled  water,  add  54  c.c.  of  a  mixture  of  equal  parts  of 
absolute  alcohol  and  ether,  and  centrifugalize  for  ten 
minutes ;  a  smear  made  of  sediment  is  fixed  to  the  slide  with 
a  drop  of  egg-albumen,  and  stained  as  usual. 

Bacillus  Typhosus. — In  typhoid  fever  is  seen  the  "pea- 
soup"  stools,  copious  in  quantity,  watery,  of  a  foul  odor, 
alkaline  in  reaction,  with  many  triple  phosphates.  In 
some  patients  limited  to  a  milk  diet,  diarrhea  is  less 
common,  and  in  occasional  cases,  constipation  is  present. 
When  the  stool  is  blood-tinged,  it  sometimes  presages  a 
hemorrhage,  though  this  is  not  a  sure  indication.  ■  Pus  is 
rare  in  typhoid  stools,  unless  in  the  presence  of  severe 
ulceration. 

To  grow  this  bacillus  from  stools  a  special  medium  is 
required,  and  for  a  detailed  description  of  the  preparation 
of  this  medium,  the  reader  is  referred  to  special  works  on 
clinical  diagnosis.     One  method,  as  shown  by  Peabody  and 


io6 


EXAMINATION   OF   THE   FECES 


Pratt,  is  to  first  use  Malachite-green  bouillon  as  an  en- 
riching medium.  (The  beef  bouillon  they  used  contained 
I :  looo  malachite  green,  and  had  an  acidity  of  0.5  per  cent, 
to  phenolphthalein,  but  the  amount  of  dye  and  acidity 
must  be  determined  for  each  preparation  of  the  malachite 
green  used.)  While  this  completely  inhibits  the  growth  of 
Bacillus  coli.  Bacillus  typhosus  will  often  grow  luxuriantly 
in  it,  although  the  dye  does  exercise  some  restraint  over  this 
organism.     Tubes  containing   15  c.c.  of  this  medium  are 


Fig.  23. — Bacillus  typhosus,  stained  to  show  flagella. 
{Oertel  after  Frankel  and  Fjeiffer.) 

inoculated  with  one  drop  of  the  fluid  stool  or  suspension  of 
the  stool,  and  are  left  in  the  thermostat  eighteen  to  twenty- 
four  hours,  and  then  one  drop  of  the  culture  is  rubbed  over 
the  surface  of  a  Drigalski-Conradi  plate. 

While  the  positive  indent ification  of  the  Bacillus  typhosus 
is  both  useful  and  interesting,  I  may  be  pardoned  for  re- 
marking that  there  are  several  other  methods  of  diagnosis 
in  this  disease  which  are  as  satisfactory  clinically,  and  are 
both  easier  and  quicker. 

Spirillum  Cholerae  Asiaticae. — This  is  a  small,  curved, 
"comma-shaped"  bacillus.  It  is  actively  motile,  and  has 
a  single  long  delicate  flagellum  at  one  end.     It  does  not 


MICROORGANISMS   IN   THE  FECES  I07 

produce  spores,  and  involution  forms  are  common.  It 
stains  readily  in  all  bacterial  stains,  and  is  decolored  by 
the  Gram  method.  It  grows  rapidly  at  ordinary  room 
temperature  on  all  commonly  used  media,  in  fact  on  some 
media  too  poor  for  other  organisms  to  grow  upon.  It  will 
not  grow  on  potato  at  room  temperature,  but  will  in  a 
thermostat.  It  is  actively  aerobic.  It  grows  in  a  charac- 
teristic manner  on  gelatin  which  it  liquefies,  and  on  the 
gelatin  plates  the  colonies  soon  appear  as  minute  white 


Fig.  24. — Cholera  spirilla.     {PUfield.) 

points,  resembling  fragments  of  broken  ground  glass  with 
granular  irregular  margins.  After  Hquefaction  begins,  the 
colony  sinks  into  the  little  cup  of  liquid  cloudy  gelatin  which 
surrounds  it  as  a  halo.  This  organism  produces  much  indol 
and  is  sensitive  to  acids. 

The  stools  in  severe  Asiatic  cholera  are  quite  character- 
istic. They  are  copious,  ejactdated  from  the  bowel  with 
but  little  effort,  and  the  water  in  them,  which  in  the  main 
is  secreted  by  the  intestinal  wall,  is  dotted  with  gray  flecks, 
these  flecks  consisting  of  masses  of  epitheUal  cells,  cholera 
spirilla  and  fat  droplets.  They  have  but  Httle  fecal  odor, 
are  alkaline,  sometimes  blood-stained,  and  contain  little 
albumen  and  much  salt. 


Io8  EXAMINATION    OF    THE    FECES 

There  are  many  other  spirilla,  pathogenic  and  non- 
pathogenic, but  their  identification  and  differentiation 
require  special  study  and  equipment.  Some  of  them  can 
only  be  recognized  by  a  specific  test  of  inoculation  of  a 
guinea-pig  or  other  animal. 

Cholera  nostras  gives  rise  to  a  profuse  diarrhea  not  unlike 
the  Asiatic  variety,  and  in  times  of  epidemic,  it  may  be 
hard  indeed  to  distinguish  between  the  two.  The  true 
diagnosis  of  Asiatic  cholera  may  be  generally  made  directly 
from  the  stools,  but  during  epidemics  of  this  disease  all 
severe  diarrheal  maladies  should  be  regarded  with  extreme 
suspicion,  whether  or  not  any  pathogenic  organisms  may  be 
found  in  the  feces. 

The  Dysentery  Bacillus  (Shiga's  Bacillus). — This  in 
shape  and  in  some  of  its  cultural  characteristics  resembles 
the  Bacillus  typhosus.  It  is  a  short  organism  with  rounded 
ends,  is  non-motile,  and  is  inclined  to  involution  forms. 
This  organism  stains  readily  in  the  commonly  used  aniline 
dyes,  showing  a  tendency  to  polar  staining,  and  is  de- 
colorized by  Gram's  method. 

This  organism,  and  others  in  its  closely  related  class, 
which  have  been  identified  by  His,  Flexner,  Harris  and 
others,  are  the  cause  of  "bacillary"  dysentery,  which  may 
occur  sporadically  or  in  severe  epidemics.  This  form  of 
dysentery  may  begin  as  an  acute  gastroenteritis  with  a 
diarrhea,  which  increases  in  severity  until  the  stools  lose 
their  fecal  character,  are  frequent,  scanty,  and  painful,  and 
contain  chiefly  mucus  and  blood  and  numerous  organisms 
of  dysentery. 

In  recognizing  these  organisms  the  agglutination  tests  are 
most  important.  The  blood  serum  of  a  patient  infected 
with  an  organism  belonging  to  the  Flexner-Harris  type 
will  agglutinate  the  pure  culture  of  this  organism  in  dilu- 
tions of  I :  looo.  In  the  Shiga  bacillus,  agglutination  is  less 
complete. 

The  physician  will  find  that  time,  thought  and  patience 
in  the  field  of  investigation  of  feces  will  be  well  spent.     This 


EXAMINATION    OF   THE   FECES  lOQ 

is  in  many  respects  a  fallow  field,  and,  as  research  work  in  it 
proceeds,  many  and  valuable  will  be  the  disclosures. 

A  test-meal  from  the  stomach  represents  the  normal  or 
abnormal  activities  of  only  a  small  portion  of  the  alimen- 
tary tract.  The  feces  in  many  ways  constitute  an  index 
of  the  workings  of  the  whole  alimentary  tract,  and  when 
rightly  read  present  a  picture  of  the  highest  possible 
diagnostic  value. 


CHAPTER  IV 

EXAMINATION    OF    THE    ESOPHAGUS,    STOMACH 
AND  INTESTINES  BY  THE  ROENTGEN  RAY 

Perhaps  no  discovery  of  recent  times  has  so  advanced 
human  knowledge  concerning  the  intimate  appearance  and 
workings  of  the  abdominal  viscera  as  the  Roentgen  or 
X-ray.  Especially  in  obscure  conditions  of  these  organs 
has  this  ray  come  to  our  aid,  and,  where  formerly  it  was 
necessary  to  perform  an  exploratory  laparotomy  to  clear 
up  an  uncertain  diagnosis,  the  Roentgen  ray  now,  in  many 
instances,  points  out  the  real  pathologic  condition  with 
unerring  precision.  Furthermore,  in  no  department  of 
X-ray  diagnosis  have  such  rapid  advances  been  made  as  in 
the  examination  of  the  abdominal  organs.  The  ordinary 
classical  methods  of  physical  examination  have  long  ago 
penetrated  the  darkness  of  the  lungs  and  chest,  but  the 
abdomen  has  been  a  terra  incognita  in  many  respects,  till 
these  rays  enabled  us  to  pierce  its  most  hidden  recesses. 

On  the  other  hand,  however,  this  method  requires  spe- 
cial and  expensive  apparatus,  expert  technic,  and  trained 
judgment;  there  is  connected  with  it  some  danger,  unless 
proper  precautions  are  taken,  and,  except  where  employed 
in  hospitals  or  special  institutions,  it  is  quite  an  expensive 
procedure,  beyond  the  means  of  individuals  in  ordinary 
circumstances.  These  disadvantages  will  probably  disap- 
pear in  the  course  of  time. 

The  X-ray  is  most  useful  in  deciding  whether  or  not  an 
operation  is  advisable,  and,  while  many  early  cases  of  malig- 
nant disease  have  been  diagnosed  and  relieved,  many  also 
have  been  spared  the  misfortune  of  needless  operations. 

In  the  diagnosis  of  diseased  states  of  the  esophagus,  the 
X-ray  has  been  partly  considered.     In  the  diagnosis  of 


EXAMINATION   OF   ESOPHAGES  III 

diverticula,  or  the  early  diagnosis  of  cancer  of  the  gullet,  it 
is  invaluable. 

The  appearance  of  the  coursing  of  the  bismuth  and  milk 
down  this  passage  has  been  described,  and  any  tortuous 
channels  leading  off  from  the  esophagus  are  easily  observed 
through  the  fluoroscope. 

One  difficulty  in  forming  a  correct  idea  of  the  size  of  any 
possible  sacculation  in  the  esophagus  has  been  in  the 
rapidity  with  which  the  contents  pass  through  into  the 
stomach.  In  the  normal  individual,  where  there  is  no 
marked  constriction  either  in  the  lumen  of  the  passage  or 
at  the  cardia,  fluids  reach  the  cardiac  end  of  the  gullet  in 
from  five  to  ten  seconds  and  solids  in  about  twice  that 
length  of  time.  To  obviate  this  quick  emptying,  it  is 
necessary,  in  order  to  obtain  a  sharply  defined  outline  of 
the  esophageal  walls,  to  plug  in  some  way  the  lower  end  of 
the  tube. 

The  best  and  most  practicable  method  of  accomplishing 
this  has  been  devised  by  Bassler,  and  described  by  him  in 
the  Journal  of  the  American  Medical  Association,  April  26, 

1913- 

For  this  purpose  he  uses  a  simple  device  made  by 
Tiemann  and  Company,  which  may  be  described  as 
follows:  To  a  120  cm.  (4-foot)  length  of  rubber  tubing 
4  mm.  in  diameter,  is  attached  a  rubber  bag  covered  with  a 
reinforcement  of  silk,  and  having  a  brass  tip  at  its  lower 
end  to  give  it  weight.  At  the  upper  end  of  the  tube  is  a 
cock.  An  ordinary  surgical  syringe  of  about  2 -ounce 
capacity  containing  water  is  used  to  distend  the  bag,  which, 
when  distended  is  fusiform  in  shape,  and  measures  about 
10  cm.  in  its  circumference.  The  tube  is  lubricated  with 
glycerin  and  passed  in  the  usual  manner  of  a  stomach-tube. 
Xt  is  allowed  to  go  down  to  beyond  a  mark  made  on  the  tube, 
about  16  inches  from  the  upper  end  of  the  bag.  After  the 
bag  is  in  the  stomach,  it  is  filled  with  water  by  means  of  the 
syringe.  This  being  done,  the  cock  is  closed,  and  the  tube 
firmly  pulled  so  that  the  elastic  bag  of  water  is  drawn 


112  EXAMINATION    OP    THE    ESOPHAGUS 

tightly  into  the  funnel-shaped  cardiac  orifice  of  the  stomach. 
The  patient  is  now  told  to  exhale  completely  so  as  to  raise 
the  dome  of  the  diaphragm  to  a  high  level,  and  the  external 
tube  held  tightly  at  this  point.  It  is  then  fastened  about 
the  forehead  or  around  the  neck  of  the  patient  with  a  secure 
knot.  Sometimes  an  external  weight  is  preferable  to  hold 
the  bag  up  against  the  cardia,  and  weight  of  1/2  to  i  pound 
is  generally  sufficient.  There  being  a  silk  string  inside  the 
tube,  there  is  no  danger  of  its  breaking.  The  cardiac  orifice 
being  occluded,  a  mixture  of  bismuth,  acacia  and  water  is 
run  into  the  esophagus  from  an  irrigating  jar  by  means  of 
an  ordinary  urethral  catheter,  a  rather  large  one  being 
best. 

About  150  c.c.  of  the  bismuth  suspension  are  placed  in  the 
irrigating  jar,  and  allowed  to  flow  in  until  the  bismuth 
mixture  appears  in  the  mouth,  showing  that  the  gullet  is 
filled.  With  the  patient  standing,  radiographs  are  then 
taken  in  the  lateral  dorsal  position,  with  the  left  back  to  the 
plate.  Such  plates  show  the  outline  of  the  esophagus  with 
any  changes  present. 

By  this  means  of  examination,  irregularities  of  the  walls 
can  be  observed,  and  it  is  possible  to  make  a  diagnosis  of 
carcinoma  of  the  gullet  long  before  any  stenosis  appears. 

After  the  plates  are  taken,  the  tube  is  allowed  to  relax  so 
the  bismuth  will  flow  into  the  stomach,  the  cock  is  opened, 
and  a  slight  upward  tension  causes  the  water  to  flow  out 
of  the  bag  either  by  pressure  or  siphonage,  and  the  ap- 
paratus is  then  withdrawn  from  the  esophagus. 

This  method  is  not  practicable  when  stenosis  is  present. 

In  1904  Rieder  devised  the  bismuth  meal,  in  which 
bismuth  was  given  mixed  with  milk,  oatmeal  or  any  other 
pultaceous  substance.  This  was  followed  by  the  bismuth 
suspension  in  and  sedimentation  by  Holzknecht;  after 
this  came  the  double  meal  by  Haudek,  and  the  dis- 
covery of  antiperistalsis  by  Jonas.  At  present  barium 
sulphate  has  almost  superseded  bismuth,  as  it  not 
only     gives    a    more     homogeneous    appearance    of    the 


EXAMINATION  BY  THE  ROENTGEN  RAY 


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Fig.  25. — Stricture  of  esophagus  from  drinking  acetic  acid.     Patient  of  Dr.  Niles. 

{Dr.  John  S.  Derr.) 
A,  Esophagus;  B,  stricture;  C,  heart  shadows. 


EXAMINATION   OF    THE    STOMACH 


"5 


Fig.  26. — Gastric  carcinoma. 

A,  Gas  in  fundus;  B,  marked  involvement  by  new  growth  of  the  lesser  curva- 
ture and  pars  pylorica;  C,  metastases  in  the  outer  part  of  the  body  of  the  stomach; 
D,  duodenum;  E,  bismuth  in  the  small  intestine;  F,  gas  in  the  splenic  flexureof 
the  colon. 

Diagnosis  proven  by  operation  in  St.  Luke's  Hospital.  Markers  at  the 
ensiform  and  umbilicus.  (Made  in  the  X-ray  laboratory  of  Dr.  Anthony 
Bassler,  New  York  City.) 


EXAMINATION   OF   THE    STOMACH  II7 

mass  in  the  stomach,  but  interferes  less  with  the  motiHty  of 
that  organ. 

The  double  test-meal  is  given  as  follows :  the  patient  takes 
the  first  bismuth  meal  at  7  a.  m.  Six  hours  later,  i  p.  m., 
he  presents  himself  at  the  office  of  the  radiographer.  A 
glance  through  the  radioscope  suffices  to  show  the  amount 
and  shape  of  the  bismuth  residue,  and  give  an  idea  of  the 
most  important  point  in  the  diagnosis — viz.,  the  motility  of 
the  stomach.  If  the  stomach  be  empty,  a  good  idea  of 
the  motility  both  of  the  stomach  and  the  intestines  may  be 
gained  by  observing  the  position  of  the  bismuth  head  and 
tail  in  the  colon. 

The  patient  then  takes  the  second  bismuth  meal,  consist- 
ing of  a  heavy  suspension  of  bismuth  carbonate  in  water. 
The  second  meal  defines  the  shape,  size  and  position  of 
the  organ,  and  completes  the  Roentgen  diagnosis. 

Dr.  Guido  Holznecht,  of  Vienna,  has  recently  furnished  a 
very  complete  study  of  the  significance  of  different  symp- 
tom complexes,  as  disclosed  by  X-ray  examination,  and 
published  in  Archives  of  the  Roentgen  Ray.  Acknowledg- 
ments are  made  to  him  for  these  groupings. 

Symptom-Complex  I. 

1.  Bismuth  residue  after  six  hours. 

2.  Normal  stomach  shadow  in  the  screen. 

3.  Achylia. 

Diagnosis. — Small  carcinoma  of  the  pylorus. 

This  symptom  group  is  almost  always  associated  with 
stenosis  of  the  pylorus  due  to  a  small  carcinoma.  There  is 
stagnation  and  loss  of  tone,  as  evidenced  by  the  bismuth 
residue,  which  may  be  a  small  one.  The  patient  may  suffer 
from  little  or  no  disturbance,  except  loss  of  appetite,  and 
slight  malaise.  This  diagnosis  is  made  more  plain,  when  we 
remember  that,  unless  there  is  stenosis,  in  the  presence  of 
achylia  there  is  generally  hypermotility,  and  the  stomach 
would  empty  itself  in  two  or  three  hours.  Ordinary 
atonic  delay  of  gastric  evacuation  never  lasts  as  long  as  six 
hours,  and  the  cause  must  be  either  stenosis  or  spasm  of  the 


Il8  EXAMINATION   OF   THE    STOMACH 

pylorus.  Pylorospasm  is  never  associated  with  achylia, 
but  with  hyperacidity. 

The  above  is  not  a  mere  empirical  symptom- complex, 
but  a  logical  one,  and  a  decided  advance  in  the  early  diagno- 
sis of  carcinoma.  Although  the  recognition  of  the  achylia 
required  the  use  of  a  test-meal  and  a  stomach-tube,  the 
clear  conception  of  the  stenosis  and  the  accompanying 
circumstances  could  not  have  been  reached  so  surely  in  any 
other  manner. 

The  radiological  examination  also  shows  that  the  new 
growth  is  small  and  operable,  since  otherwise  there  would 
be  some  defect  in  shape  or  extent  of  the  bismuth  shadow. 
Diffuse  contracting  carcinoma,  or  deep  circumscribed 
scirrhus  would  also  show  symptoms  of  achylia  and  loss  of 
motility.  This,  however,  would  not  give  a  normal  gastric 
picture,  but  one  showing  shrinkage  and  defective  filling. 

Symptom-complex  I  (A). 

1.  Bismuth  residue  after  six  hours. 

2.  Normal  shadow  of  the  stomach. 

3.  Schwarz's  fibrodermic  capsule  intact  after  five 
hours. 

Diagnosis. — Small  carcinoma  of  the  pylorus. 
Symptom-complex  I  (B). 

1.  Bismuth  residue  in  stomach  after  six  hours, 

2 .  Head  of  the  bismuth  column  in  hepatic  flexure. 

3.  Normal  stomach  shadow. 
Diagnosis. —  Small  carcinoma  of  the  pylorus. 

The  examination  of  the  stomach  for  such  a  symptom 
group  as  the  above  is  much  more  practicable  when  the 
"double  bismuth  meal "  is  taken.  The  patient  should  take 
a  Rieder  meal  at  7  a.  m.,  and  should  see  the  radiographer  at 
I  p.  m.  A  previous  test-meal  has  shown  achylia.  At  a 
glance  it  is  observed  that  there  is  a  residue  in  the  stomach, 
and  that  the  head  of  the  bismuth  column  is  in  the  splenic 
ilexiu"e.  Carcinoma  is  at  once  suspected.  The  second 
Rieder  meal  is  now  given,  an  aqueous  suspension  of 
bismuth.     The  form,  position,  size,  and  evacuation  of  the 


EXAMINATION   OF    THE   STOMACH 


119 


Fig.  27. — Carcinoma  near  the  cardia.    Patient  of  Dr.  Niles.     {Skiagraph  by 

Dr.  John  S.  Derr.) 
A,  Roughening  caused  by  malignancy  of  growth;  C  and  D,  peristaltic  contrac- 
tions; B,  normal  cap.    Marker  at  umbilicus. 


EXAMINATION    OF    THE    STOMACH 


121 


Fig.  28. — Horn-shaped  contracted  stomach.     Inoperable  carcinoma.     Patient 

of  Dr.  Willis  Jones.     {Skiagraph  by  Dr.  John  S.  Derr.) 

A,  Antrum  almost  obliterated  by  tumor;  marker  at  umbilicus. 


EXAMINATION   OF   THE    STOMACH  1 23 

stomach  are  shown  to  be  normal,  and  the  radiological 
examination  of  the  stomach  is  complete. 

This  symptom-complex  might  apply  to  an  old  callous 
ulcer  with  achylia,  the  latter  being  due  to  alteration  in  the 
mucous  membrane,  and  the  loss  of  motility  to  invasion  of 
the  pylorus.  Such  a  case,  however,  would  show  a  snail- 
shaped  stomach  with  transverse  and  longitudinal  contrac- 
tions, and  displacement  of  the  pylorus  to  the  left. 

Symptom -complex  II. 

1.  No  residue  after  six  hours. 

2.  Marked  defect  in  gastric  shadow. 

3.  Horn-shaped  stomach. 

Diagnosis.- — Carcinoma.     No  stenosis.     Inoperable. 

Patients  with  such  a  picture  may  show  no  clinical  symp- 
toms, except  anorexia  and  loss  of  weight,  but  derive  little 
or  no  benefit  from  gastroenterostomy.  The  marked  defect 
in  the  gastric  shadow  shows  clearly  the  presence  of  a  tumor, 
but  this  tumor  is  inoperable.  Haudek  has  shown  that  when 
the  stomach  has  lost  its  hook  form  from  contraction,  and  has 
attained  the  horn  form,  it  is  no  longer  capable  of  complete 
resection.  This  form  of  the  stomach  can  only  be  due  to 
one  of  two  causes — hypertonicity  or  shrinkage.  The  first 
is  ruled  out  by  the  nature  of  the  case,  since  the  tone  of  the 
stomach  walls  would  be  impaired  by  the  commencing 
cachexia.  When  the  palpable  tumor  is  small,  we  may  be 
sure  there  is  something  else  behind,  and  that  the  shrinkage 
is  due  to  some  widespread  infiltration,  which  renders  the 
resection  inadvisable.  On  the  other  hand,  when  the 
stomach  retains  its  ordinary  physiologic  hook  form,  we  may 
with  propriety  consider  the  case  to  be  operable.  This 
radiological  conclusion  is  logical  and  of  importance. 

Symptom-complex  III. 

1.  No  residue  after  six  hours. 

2 .  Marked  defect  in  the  shadow  in  the  pars  media 
or  pars  pylorica. 

3.  Hook-shaped  stomach. 

Diagnosis. — Carcinoma  of  the  stomach.     Operable. 


124  EXAMINATION    OF    THE    STOMACH 

Symptom -Complex  IV. 

1.  Small  residue  after  six  hours. 

2.  Sensitive  pressure-point  over  the  stomach. 

3.  Normal  stomach  shadow. 
Diagnosis. — Simple  gastric  ulcer. 

This,  in  addition  to  a  previous  test-meal,  showing  either 
marked  acidity  or  the  presence  of  occult  blood,  makes  the 
diagnosis  fairly  certain.  In  all  cases  of  gastric  ulcer  there 
is  a  certain  impairment  of  the  motility.  Haudek  has  never 
found  an  ulcer  of  the  stomach  without  this  delay  in  the 
evacuation  of  this  organ,  and  no  case  of  pyloric  spasm  with- 
out some  lesion  of  the  stomach  wall.  As  regards  the 
pressure-point,  it  is  not  enough  to  merely  find  a  sensitive 
point  somewhere  in  the  epigastrium.  The  radiograph 
should  show  that  the  pressure-point  falls  on  the  lesser 
curvature  of  the  stomach  where  an  ulcer  is  most  frequently 
situated,  and  that  it  moves  with  the  stomach  by  pressure  or 
indrawing  of  the  abdominal  walls  (Jonas). 

Diagnosis  of  gastric  ulcer  by  means  of  the  X-ray,  will  be 
more  fully  considered  later  in  the  chapter. 

Symptom-complex  V. 

1.  Small  bismuth  residue  after  six  hours. 

2.  Pressure-point. 

3.  Displacement  upward  and  to  the  left. 

4.  Snail  form  of  the  stomach  shadov/. 
Diagnosis. — Old  contracting  ulcer  on  the  lesser  curvature 

of  the  pars  pylorica. 
Symptom -complex  VI. 

1.  Small  bismuth  residue  after  six  hours. 

2.  Pressure-point    and    resistance    in    the    pars 
media. 

3.  Transverse  contraction  of  the  pars  media. 

4.  Diverticulum  without  air  bubble  in  the  smaller 
curvature,  immovable. 

Diagnosis. — Callous  ulcer  of  the  pars  media. 
Even  where  a  sensitive  pressure-point  is  absent,  the  com- 
bination, hyperacidity,  with  a  small  residue  after  six  hours, 


EXAMINATION    OF    THE    STOMACH 


125 


Fig.  29. — Gastric    ulcer    (chronic    non-indurated).     Diagnosis    proven    by 
operation  in  New  York  Polyclinic  Hospital.     Markers  at  the  ensiform  and  um- 
bilicus.    {Made  in  X-ray  laboratory  of  Dr.  Anthony  Bassler,  New  York  City.) 
A,  Stomach;  B,  ulcer,  in  posterior  wall  of  pars  pylorica;  C,  pyloris;  D,  duodenal 
cap;  E,  cecum  and  ascending  colon. 


EXAMINATION   OP   THE   STOMACH 


127 


Fig.  30. — Dilated  stomach,  19  hours  retention  due  to  pylorospasm.     {Made  in 
the  X-ray  laboratory  of  Dr.  Anthony  Bassler,  New  York  City.) 
A,  Gas  in  fundus;  B,  B,  transversely  and  longitudinally  enlarged  stomach; 

C,  tight  pyloris;  D,  first  part  of  duodenum.     Markers  at  the  ensiform  and 

umbilicus. 


EXAMINATION   OF   THE    STOMACH  1 29 

is  almost  characteristic  of  ulcer,  according  to  the  radiologists. 
This  conclusion  is  not  yet  accepted  without  reservation  by 
the  internists. 

Symptom-complex  VII. 

Large  sickle-shaped  residue  after  six  hours. 

Diagnosis. — Old  stenosis  of  the  pylorus,  due  to  ulcer. 

This  symptom  is  due  to  dilatation  and  secondary  atonic 
alteration  of  the  musculature,  with  great  loss  of  motility. 

Symptom -complex  VII  (A). 

1.  Large  residue  after  six  hours. 

2.  Dilatation. 

3.  Loss  of  tone. 
Diagnosis.^ — ^O'ld  ulcer-stenosis. 

The  above  symptoms,  however,  do  not  afford  clear  in- 
formation as  to  the  character  of  the  lesion — whether  a 
simple  ulcer,  a  callous  ulcer,  or  a  carcinoma  on  the  base  of 
an  old  ulcer.  To  better  decide  this  question  it  is  well  to 
consider  the  following : 

Symptom-complex  VIII. 

1.  Large  sickle-shaped  residue. 

2.  Marked  defect  in  the  filling  of  the  pars  pylorica. 
Diagnosis. — Carcinoma  on  the  base  of  an  old  ulcer,  with 

stenosis. 

This  picture  is  fairly  common.  It  has  been  recently 
advanced,  and  with  reason,  that  a  marked  stenosis  of  the 
pylorus  with  dilatation  and  paralysis,  might  exist  without 
vomiting  or  other  severe  symptoms.  Vomiting  might  set 
in  later,  not  necessarily  from  the  stenosis,  but  from  the 
commencing  carcinoma.  The  signs  of  dilatation  and  vomit- 
ing, and  the  previous  history  of  ulcer,  all  point  to  stenosis  of 
the  pylorus,  and  do  not  contraindicate  operation. 

Symptom-complex  IX. 

1.  No  bismuth  residue  after  six  hours. 

2.  Marked    defect   in   the    shadow   of   the   pars 
pylorica  or  pars  media. 

3.  Transverse  constriction  of  the  greater  curva- 
ture. 


130  .  EXAMINATION   OF   THE    STOMACH 

Diagnosis. — Carcinoma  on  the  base  of  an  old  ulcer.  No 
stenosis. 

Symptom-complex  X. 

1.  Stomach  empty  after  six  hours.     Head  of  the 
bismuth  column  at  splenic  flexure  of  colon. 

2.  Shortening  of  the  stomach. 

3.  Congestion  at  the  cardia. 
Diagnosis. — Carcinoma  of  the  pars  cardiaca. 
Symptom  I  indicates  hypermotility  of  the  stomach  due 

to  hypoacidity  or  anacidity.  This  should  be  confirmed  by  a 
second  examination  three  hours  after  the  bismuth  meal. 
Symptom  II  indicates  a  diffuse  contraction,  and  indicates 
carcinoma.  Symptom  III  points  to  the  rapid  encroach- 
ment and  advance  of  the  pathologic  process.  The  achylia 
renders  the  diagnosis  of  ulcer  untenable.  The  condition  is 
probably  inoperable. 
Symptom-complex  XI. 

1.  Stomach    empty    after    six    hours.     Head    of 
bismuth  column  in  the  ascending  colon. 

2.  Stomach  shadow  normal. 

3.  Pressure-point  moving  with  the  duodenum. 
Diagnosis. — Duodenal  ulcer. 

Symptom -complex  XII.     Normal  stomach. 

1 .  Stomach  empty  in  six  hours.     Head  of  bismuth 
column  in  the  ascending  colon. 

2.  Stomach  shadow  normal. 

3.  No  increase  of  peristalsis;  no  antiperistalsis. 

4.  HCl  normal. 

This  is  the  picture  of  a  normal  stomach,  and  in  no  case 
showing  these  signs  has  been  found  any  anatomical  altera- 
tions on  operation  or  post-mortem  examination. 

It  should  always  be  remembered,  however,  that  the  less 
number  of  positive  symptoms,  the  greater  care  is  necessary 
in  the  Roentgen  examination,  and  the  greater  caution  should 
be  observed  in  expressing  an  opinion. 

In  addition  to  the  symptom-complexes  so  interestingly 
and  clearly  brought  out  by  Holzknecht,  and  pointing  to  the 


EXAMINATION    OF    THE    STOMACH 


131 


Fig.  31. — Six-hour   residue.     Pyloric   Stenosis.     Confirmed   at   operation. 

Patient  of  Drs.  L.  L.  Andrews  and  E.  G.  Jones.     {Dr.  John  S.  Derr.) 

A,  Six-hour  residue;  B,  duodenum.     Marker  on  umbilicus. 


EXAMINATION   OF   THE    STOMACH 


133 


Fig.  32. — Gastroptosia  (moderate)  with  hypermotility.     {Made  in  the  X-ray 
laboratory  of  Dr.  Anthony  Bassler,  New  York  City.) 
A,  Gas  in  the  fundis;  B,B,  rugae;  C,  pars  pylorica  with  hypermotility;  D, 
pyloric  muscle;  E,  normal  duodenal  cap;  F,  third  part  of  duodenum;  G,  liver 
shadow.     Markers  at  the  ensiform  and  umbilicus. 


EXAMINATION    OF    THE    STOMACH 


13s 


Fig.  S3- — Pyloric  stenosis  from  adhesions  to  gall-bladder.  Confirmed  at 
operation  by  Dr.  E.  C.  Davis.  The  stones  filling  the  gall-bladder  did  not  show 
in  skiagraph.     {Dr.  John  S.  Derr.) 

A,   Deformity  of    pylorus   due   to   adhesions;   B,   deformed   cap.     Marker  at 

umbilicus. 


EXAMINATION    OF    THE    STOMACH 


137 


Fig.  34. — Atony  and  dilatation  of  stomach.  Pyloric  stenosis.  Non-malig- 
nant. Diagnosis  confirmed  at  operation.  Patient  of  Dr.  L.  L.  Andrews. 
{Dr.  John  S.  Derr.) 

A,  Gas  in  cardia;  B,  remains  of  duodenal  cap;  C,  pylorus.     Marker  hidden  by 

stomach  shadow. 


X-RAY   SIGNS    OF   ULCER  I39 

diagnosis  of  gastric  ulcer,  there  have  been  a  number  of 
important  studies  and  experiments  in  which  the  X-ray 
was  employed  to  diagnose  this  condition.  In  1907  Jolasse 
reported  that  he  had  seen  a  patch  of  bismuth  showing  in  the 
skiagram  of  a  patient  suffering  from  gastric  ulcer.  In 
the  same  year  Hemmeter  performed  a  number  of  ex- 
periments on  cats  and  rabbits,  in  whom  he  artificially 
produced  deep  ulcerations  in  the  pylorus.  These  ulcers 
were  treated  with  bismuth,  and  if  the  animals  were  kept 
without  fluid,  the  bismuth  spots  could  be  seen  on  the 
screen  twenty-four  hours  later.  Later  on,  Haudek  and 
Clairmont  made  a  number  of  other  experiments  with  ani- 
mals, and  their  observations  corroborated  Jolasse. 

Leaving  out  the  very  technical  details  which  lead  up  to  the 
conclusions,  Haudek  cites  the  following: 

1 .  A  fiat  ulcer  of  the  stomach  does  not  give  any  shadow, 
due  to  the  deposition  of  bismuth  on  its  surface. 

2.  Any  abnormal  circumference  shadow,  which  is  seen 
after  a  bismuth  meal  is  due  to  the  enclosure  of  the  bismuth 
in  a  pathological  pocket,  or  diverticulum. 

3.  A  penetrating  ulcer  of  the  stomach  may  frequently 
give  rise  to  a  special  appearance — an  outgrowth  or  diver- 
ticulum of  the  bismuth  shadow,  with  an  air  bubble  at  its 
summit. 

The  radiological  signs  of  a  penetrating  ulcer  of  the 
stomach  are  as  follows : 

1.  A  patch  or  streak  of  bismuth,  isolated  from  the  mass 
of  the  bismuth  meal,  or  branching  out  from  it,  usually  at 
the  lesser  curvature  and  in  the  pars  media  of  the  stomach. 

2.  A  gas-bubble  at  the  summit  of  this  isolated  patch. 

3.  Retention  of  the  bismuth  for  a  considerable  time  in 
this  region. 

4.  Immobility  of  the  bismuth  patch,  which  is  not  in- 
fluenced by  palpation  or  pressure. 

Haudek  also  concludes  that  penetrating  gastric  ulcer  is 
by  no  means  uncommon,  and  that  the  reason  that  they 
have  been  previously  overlooked,  lies  in  the  fact  that  no 


I40  EXAMINATION   OF   THE    STOMACH 

reliable  diagnostic,  means  for  their  detection  have  been 
available. 

In  the  Roentgen  ray  we  have  the  most  convincing 
methods  of  diagnosing  that  interesting  and  sometimes 
confusing  condition,  the  hour-glass  stomach.  This  condi- 
tion is  divided  by  pathologists  into  two  groups — congenital 
and  acquired.  The  existence  of  the  former  is  denied  by 
good  observers  like  Mayo  Robson  and  Moyihan,  the  latter 
ascribing  the  so-called  congenital  hour-glass  contraction  to 
one  of  three  causes — gastric  ulcer,  adhesions  in  the  stomach 
or  its  walls,  and  carcinoma. 

Acquired  hour-glass  contraction  is  generally  the  result  of 
cicatricial  contraction  of  a  healing  gastric  ulcer.  This 
ulcer  is  usually  situated  on  the  lesser  curvature,  and  has 
extended  to  the  long  axis  of  the  stomach ;  or  there  may  have 
been  two  ulcers,  one  on  either  side  of  the  lesser  curvature. 
In  consequence  of  the  resulting  contraction,  the  stomach 
appears  to  be  divided  into  two  pouches,  the  larger  corre- 
sponding to  the  fundus,  the  smaller  to  the  pyloric  end  of  the 
viscus.  The  sulcus  separating  the  two  in  generally  of 
considerable  length,  and  is  usually  situated  somewhat 
nearer  to  the  pylorus  than  the  cardia.  In  some  cases  the 
stomach  is  adherent  to  the  pancreas  or  to  the  undersurf  ace 
of  the  liver,  and  occasionally  the  pyloric  portion  is  dilated, 
the  result  of  a  coincident  cicatricial  or  spasmodic  stenosis  of 
the  pylorus. 

Robson  and  Myonihan  have  reported  two  instances  of  the 
stomach  being  divided  into  three  pouches  by  two  constric- 
tions, making  the  so-called  "trifid  stomach." 

Dr.  Robert  Knox  has  contributed  a  valuable  study  on 
the  X-ray  diagnosis  of  hour-glass  stomach,  and  acknowledg- 
ments are  given  for  assistance  in  the  preparation  of  this 
section. 

The  symptoms  of  this  condition  are  fairly  characteristic, 
though  at  times  somewhat  indefinite.  At  first  the  symp- 
toms appear  to  depend  on  the  original  cause,  while  later 
on  the  condition  itself  may  be  diagnosed,  if  sufficient  care 


EXAMINATION    OF   THE    STOMACH 


141 


Fig.  35. — Hour-glass  contraction  of  stomach.     Patient  of  Dr.  L.  S.  Hardin. 

{Dr.  John  S.  Derr.) 
A,  Dilated  cardia;  B,  hour-glass  contraction;  C,  peristaltic  waves;  D,  antrum; 

E,  cap. 


EXAMINATION    OF    THE    STOMACH 


143 


Fig.  36. — Water-trap  stomach.     Patient  of  Dr.  L.  C.  Fischer, 
operation.     {Dr.  John  S.  Derr.) 
A,  Long  pyloric  arm.     Marker  at  umbilicus. 


Confirmed  at 


EXAMINATION    OF    THE    STOMACH  145 

and  patience  are  exercised.     The  following  are  the  char- 
acteristic symptoms  of  hoiir-glass  contraction: 

1.  Pain  after  a  meal,  coming  on  at  once  or  after 
some  time. 

2.  Vomiting  of  the  stomach  contents,  and  some- 
times also  blood. 

3 .  Emaciation  slowly  increasing. 

4.  The  presence  of  a  tumor,  due  to  cicatrization 
of  an  old  ulcer  with  absence  of  ascites  and 
secondary  nodes. 

These  symptoms  may  for  a  time  simulate  stenosis  of  the 
pylorus,  the  condition  lasting  for  years,  and  causing  great 
suffering.  Fatal  hemorrhage  may  occur,  in  which  all  the 
blood  enters  the  bowel,  and  the  patient  may  die  without 
showing  any  of  the  diagnostic  signs  of  bleeding  into  the 
stomach.  This  has  been  denominated  "hematemesis  into 
the  intestine." 

It  will  be  noted  that  during  lavage  of  the  stomach  all  of 
the  fluid  fails  to  return.  Often  after  an  apparently 
thorough  lavage,  a  further  quantity  of  stomach  contents 
makes  its  appearance.  This  is  foul  and  bad-smelling,  and 
several  times,  after  the  stomach  has  seemingly  been 
washed  clean,  another  lavage  will  show  these  signs  of 
retained  contents. 

Another  symptom  of  worth  is  a  splash  on  palpation  of  the 
stomach  after  the  apparent  removal  of  all  of  its  contents. 
Sometimes,  on  percussing  the  empty  stomach,  and  again 
percussing  it  after  distention,  a  change  in  the  position  of  the 
tumor  may  be  observed.  The  proximal  pouch  is  first  dis- 
tended, then  the  distal  pouch.  Occasionally  the  notch 
between  the  two  tumors  is  noticeable  after  distention. 
On  dilatation,  bubbling  and  sizzling  sounds  may  be  heard 
through  the  stethoscope  some  distance  from  the  pylorus. 
Patients  are  sometimes  themselves  conscious  of  this  symp- 
tom, as  the  food  passes  from  one  pouch  to  the  other. 

Some  years  ago  a  middle-aged  woman  came  under  my 
notice,  in  whom  the  diagnosis  of  hour-glass  stomach  could 


146  EXAMINATION   OF    THE    STOMACH 

be  made  by  palpation.  She  reported  extreme  fullness  in  the 
epigastrium,  which  was  relieved  as  the  food  was  emptied 
in  the  second  pouch.  Unfortunately  I  lost  sight  of  her, 
and  am  unable  to  report  her  present  condition.  I  was  un- 
able at  the  time  to  get  her  in  touch  with  a  radiologist. 

An  examination  of  the  stomach  after  a  bismuth  meal 
affords  a  positive  diagnosis  of  this  trouble.  The  movements 
of  the  stomach  may  be  observed,  the  passage  of  the  meal 
may  be  watched  as  it  progresses  from  the  cardiac  to  the 
pyloric  segment,  and  a  series  of  radiograms  may  be  obtained 
of  the  position  and  appearance  of  the  bismuth  meal  at 
successive  intervals.  By  this  method  the  operator  may  also 
learn  the  exact  time  which  the  stomach  takes  to  empty 
itself,  and  thus  be  enabled  to  estimate  the  degree  of  ob- 
struction present  in  a  particular  case. 

For  the  detection  of  foreign  bodies  in  the  stomach  or 
intestines  the  X-ray  is  invaluable.  Pieces  of  metal  can 
be  easily  located,  and  followed  during  their  progress,  shoiild 
such  take  place.  Two  year  ago  there  was  sent  me  a  girl 
twelve  years  of  age,  who  reported  swallowing  an  iron  tap, 
about  1/2  inch  in  diameter.  The  tap  was  four-cornered, 
with  rather  sharp  edges  and  corners,  and  it  was  hard  to 
realize  how  she  got  it  down  her  esophagus.  An  X-ray  ex- 
amination quickly  located  it  in  her  stomach,  from  which 
it  was  removed. 

Dr.  C.  Thurston  Holland  reports  the  radiography  of  a 
hairball  in  the  stomach,  in  which  the  viscus  was  so  filled  by 
the  mass  of  hair  that  the  barium  mixture,  which  was  used 
in  this  instance,  only  left  rather  indistinct  shadows  around 
the  walls  of  the  stomach,  though  the  food  could  be  seen 
"flowing"  through  the  pylorus  into  the  duodenum. 

Biliary  calculi  are  sometimes  clearly  brought  out  by 
radiography,  but  at  present  the  radio- diagnosis  of  chole- 
lithiasis is  subject  to  many  errors,  and  a  positive  diagnosis 
is  quite  exceptional  for  the  following  reasons,  as  adduced 
by  Dr.  Jaugeas: 

' '  Biliary  calculi  are  as  a  rule  exclusively  organic  in  chem- 


EXAMINATION    OF    THE    INTESTINES 


147 


Fig.  37. — ^Lane's  kink  and  coloptosis.     (Made  in  the  X-ray  laboratory  of  Dr. 

Anthony  Bassler,  New  York  City.) 

A,  Cecum;  B,  Lane's  kink;  C,  transverse  colon;  D,  sigmoid;  E,  dilated  rectum. 

Markers  at  the  ensiform  and  umbilicus. 


EXAMINATION   OF   THE   INTESTINES 


149 


Fig.  38. — Rectal  injection  of  colon  and  appendix.     Patient  of  Dr.  G.  H.  Noble. 

{Dr.  John  S.  Derr.) 

A,  Appendix;  B,  transverse  colon;  C,  cecum;  D,  splenic  flexure;  E,  sigmoid. 

Marker  on  umbUicus. 


EXAMINATION   OF   THE   INTESTINES  151 

ical  composition,  being  composed  of  cholesterin,  biliary  pig- 
ment, biliary  acids,  etc.,  which,  owing  to  their  great  trans- 
parency to  the  X-rays,  show  but  little  contract  to  the  ab- 
dominal opacity.  In  rare  cases,  however,  calcium  salts 
are  added  to  these  organic  substances  in  such  proportion 
as  greatly  to  increase  the  density  of  the  calculus.  Between 
the  cholesterin  type  and  the  calcareous  type  are  a  great 
number  of  intermediary  forms,  varying  in  the  proportion 
of  salts  which  they  contain.  The  presence  of  calcium  is, 
indeed,  the  sole  condition  of  visibility.  Other  factors 
also  may  interefere  with  the  radio-diagnosis,  as  the  presence 
of  bile  in  the  gall-bladder,  its  concentration,  and  the 
thickening  of  the  vesicular  walls  attenuate  the  contrast  of 
the  image,  and  may  entirely  efface  it  where  the  opacity  of 
the  calculus  is  not  great." 

The  matter  is  rendered  even  more  difficult  by  the 
situation  of  the  bile  ducts  on  the  lower  surface  of  the 
liver,  where  they  are  easily  confounded  with  the  shadow  of 
the  hepatic  parenchyma  and  the  abdominal  organs.  To 
this  there  is,  however,  one  exception — the  common  bile 
duct.  This  is  frequently  the  seat  of  biliary  calculi,  and  its 
image  may  always  be  clearly  separated  from  that  of  the 
liver.  Muscularity  of  the  abdominal  walls  and  obesity 
add  greatly  to  the  difficulties,  but  notwithstanding  all  the 
disadvantages  mentioned,  a  radiographic  examination 
should  never  be  neglected  when  practicable,  since  a  certain, 
although  limited  number  of  cases  yield  a  positive  diagnosis. 

The  further  we  go  down  the  digestive  tract  and  away  from 
the  stomach,  the  less  useful  in  some  respects  are  the  X-rays 
for  diagnosis.  The  topographical  aspect  of  the  small  in- 
testine is  made  out  with  great  difficulty,  the  hardest  part  of 
all  being  the  duodenum. 

In  stenosis  of  the  duodenum  the  pylorus  may  be  seen 
open  and  pulled  down.  Under  normal  conditions  only  the 
pars  superior  horizontalis  is  seen  in  the  duodenum,  and  at 
no  time  are  there  contractions  visible;  but  in  the  case  of 


152  EXAMINATION   OF    THE   INTESTINES 

stenosis  we  sometimes  get  the  entire  duodenum  filled,  and 
visible  peristalsis. 

Haudek  claims  that  autopsy  findings  have  established 
the  fact  that  whenever  the  symptoms  of  ulcer  of  the 
stomach  were  associated  with  hypermotility  of  the  stomach 
during  life,  the  ulcer  was  usually  found  at  the  duodenum. 

The  course  of  the  rest  of  the  small  intestine  soon  after  a 
m.eal  is  seen  only  in  a  few  bismuth  spots  in  the  hypo- 
gastrium;  later  larger  masses,  resembling  caluiflower,  are 
seen.  In  the  majority  of  cases  we  observe  only  individual 
curls  resembling  the  small  intestine. 

Gross,  with  his  intestinal  tube,  has  succeeded  in  getting 
250  cm.  of  bismuth  injected,  and  has  outlined  the  small 
intestine  fairly  well.  Novak  has  shown  that  the  existence 
of  small  helminthiform  masses  in  the  region  of  the  small 
intestine  indicates  stenosis. 

The  Colon. — The  position  of  this  gut  is  best  studied  by 
the  bismuth  bolus  enema.  For  the  functional  test  of  the 
intestines  the  use  of  the  Rieder  meal,  and  watching  the 
progress  of  this  meal  through  the  entire  intestinal  tract  is 
more  satisfactory.  The  distention  of  the  colon  by  air  is 
troublesome  to  the  patient,  and  gives  a  blurred  picture. 
The  colon  is  usually  recognized  by  the  haustra,  and  the 
cecum  cannot  be  separated  from  the  ascending  colon.  The 
transverse  colon  does  not  run  horizontally,  but  runs  in  a 
line  with  the  greater  curvature  of  the  stomach,  and  the 
haustra  are  specially  well  marked  in  this  portion  of  the  gut. 

From  the  splenic  flexure  the  descending  colon  takes  a 
straight  downward  course,  with  a  slight  narrowing  at  the 
sigmoid  flexure.  The  entire  colon  in  its  normal  condition  is 
quite  movable. 

The  passage  of  food  in  the  presence  of  normal  motility 
varies  considerably,  but,  according  to  the  consensus  of 
opinion,  may  be  located  in  its  onward  course  about  as 
follows:  The  small  intestines  are  seen  from  a  half  hour 
after  the  meal  is  taken  up  to  four  or  flve  hours ;  the  cecum 
and  colon  are  seen  about  four  to  six  hours  after  the  meal; 


COLOPTOSIS 


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EXAMINATION    OF    THE    INTESTINES 


155 


Fig.  40. — Rectal  injection  showing  dilatation  and  atony  of  cecum,  kinking 
of  splenic  flexure  of  sigmoid.  Operated  on  successfully  by  Dr.  J.  N.  Ellis 
{Dr.  John  S.  Derr.) 

A,  Cecum;  B,  hepatic  flexure;  C,  sigmoid;  D,  splenic  flexure  filled  with  gas; 
E,  gas  in  kinked  sigmoid. 


EXAMINATION    OF   THE   INTESTINES  1 57 

the  transverse  colon  ten  to  twelve  hours,  and  it  may  be 
sometimes  observed  at  the  ampiilla  of  the  rectum  for  as 
much  as  twenty-four  hours. 

To  make  out  the  position,  shape  and  size  of  the  colon,  as 
well  as  to  discover  any  other  pathologic  states  there,  such 
as  constricting  bands  or  kinks,  it  is  necessary  to  fill  this  gut 
with  a  bismuth  or  barium  suspension. 

The  technic  of  this  procedure,  though  simple  in  details, 
requires  considerable  tact  and  patience  in  order  to  fill  the 
colon  without  so  rapidly  distending  and  disturbing  it  that 
the  contents  are  ejected  before  a  satisfactory  radiograph 
can  be  made. 

The  method,  as  described  to  me  by  Dr.  J.  S.  Derr,  is  as 
follows:  Four  ounces  of  barium  sulphate  is  placed  in 
about  2  quarts  of  good  buttermilk  of  a  homogeneous 
character.  The  lumpy  buttermilk,  or  what  which  is  stale 
will  not  answer.  The  buttermilk  is  warmed  to  a  body 
temperature  and  the  barium  thoroughly  mixed  with  it. 
The  patient  is  placed  on  the  left  side,  and  the  milk  slowly 
injected  from  either  a  fountain  syringe  or  a  porcelain  douche 
container  hung  at  not  too  great  height.  It  should  flow 
through  a  colon  tube  carefully  and  gently  introduced.  As 
the  injection  proceeds,  the  patient  is  placed  in  the  knee- 
chest  position,  and  kept  there  until  the  colon  is  fairly  well 
filled.  He  is  held  in  this  position  for  a  few  minutes  and  then 
gradually  "eased  down"  on  his  right  side.  Then  in  a  brief 
space  of  time  the  exposure  is  made  with  the  patient  prone, 
face  downward. 

In  many  instances  an  X-ray  examination  of  the  ab- 
domen will  diclose  various  abnormalities  of  the  enclosed 
viscera,  as  to  position  (especially  ptosis),  changes  in  the 
relative  position  of  one  organ  to  another,  and  other  dis- 
closures of  interest.  These  disclosures  will  in  many  cases 
clear  up  an  obscure,  perhaps  vexed  diagnosis,  making  plain 
many  symptoms  not  previously  understood. 

On  the  other  hand,  in  closing  this  chapter,  let  me  caution 
the  reader  that  many  apparently  pathologic  conditions  of 


158  EXAMINATION    OF    THE    INTESTINES 

the  abdominal  viscera,  as  disclosed  by  the  Roentgen  ray, 
give  a  history  of  no  subjective  symptoms,  nor  is  there  that 
distress  present  which  the  radiographs  would  lead  the 
observer  to  expect. 

After  all,  the  X-ray  is  one  of  many  aids  to  diagnosis,  and, 
while  it  marks  a  wonderful  advancement  in  our  knowledge 
in  gastrointestinal  ailments,  and  is  invaluable  in  some 
pathologic  conditions,  it  must  not  be  depended  on  en- 
tirely, to  the  exclusion  of  other  and  well-tried  methods. 


CHAPTER  V 
IS  THE  CASE  STRICTLY  SURGICAL? 

This  treatise  does  not  purport  to  be  a  work  on  abdominal 
surgery.  There  are  some  gastrointestinal  conditions  requir- 
ing surgery  and  that  alone,  and  in  the  presence  of  which, 
temporizing  with  internal  or  palliative  methods  may  lose 
for  the  patient  his  "day  of  grace." 

Of  necessity,  many  of  these  conditions  cannot  be  gauged 
by  any  inflexible  or  arbitrary  rule,  and  consequently  some 
of  the  decisions  are  colored  by  the  personal  equation  or 
personal  bias  of  the  physician  or  surgeon. 

Instances  are  numberless  in  which,  after  some  competent 
and  conscientious  surgeon  had  advised  immediate  opera- 
tion, in  order  that  life  might  be  saved,  the  patient  after- 
ward recovered  without  the  operation,  perhaps  outliving 
the  surgeon. 

On  the  other  hand,  mournfully  many  are  the  procrasti- 
nating invalids,  who  put  off  from  time  to  time  the  inevitable 
operation,  until,  when  the  adbomen  is  opened,  there  can  be 
absolutely  nothing  done. 

Then,  there  are  the  many  "border-line"  cases,  which 
puzzle  both  the  internist  and  surgeon,  and  which,  in  spite  of 
the  closest  consideration,  may  remain  puzzles  for  months 
and  years. 

The  conclusions  advanced  in  this  brief  chapter  may  not 
meet  with  the  approval  of  all  its  readers,  and  I  fully  realize 
my  inability  to  prove  some  of  the  deductions  herein  con- 
tained. I  might  affirm,  however,  that  each  statement 
is  based  on  actual  experience  or  observation,  and  not  on 
hearsay. 

IS9 


l6o  IS    THE    CASE    STRICTLY    SURGICAL? 

EARLY  MALIGNANT  GROWTHS  IN  THE 
STOMACH  OR  INTESTINES 

Such  patients,  when  this  condition  is  diagnosed,  should  be 
urged  to  undergo  operative  interference  without  delay. 
Palliative  measures  of  the  internist  are  permissible  only  to 
prepare  for  the  operation,  or,  when,  for  some  reason, 
surgery  cannot  or  may  not  be  undertaken. 

In  some  cases,  where  previous  malignancies  have  been 
in  evidence,  it  is  not  wise  to  wait  even  for  a  positive  diag- 
nosis, but  surgery  should  be  recommended  at  the  first  sus- 
picious symptom. 

There  consulted  me  several  months  ago  a  widow  of  fifty, 
who  had  previously  had  her  breast  extirpated  for  a  cancer- 
ous growth.  There  was  no  tumor,  but  little  epigastric 
soreness,  and  she  did  not  look  specially  ill.  A  test-meal 
disclosed  nothing  of  importance,  while  an  X-ray  gave  only 
a  faint  irregularity  of  the  lower  stomach-line,  an  unimpaired 
"duodenal  cap,"  and  practically  no  six-hour  residue. 

On  the  other  hand,  she  showed  a  decided  cachexia,  she 
had  lost  lo  pounds  in  weight  within  six  weeks,  and  she  had 
an  indefinite  and  constant  sensation  of  ill-being  in  her 
stomach.  No  one  could  have  diagnosed  cancer  of  the 
stomach  de  novo  in  such  a  case,  but,  taking  her  history  and 
other  collateral  circumstances,  I  urged  an  immediate 
operation. 

This  operation  disclosed  a  small,  malignant  infiltration  of 
the  greater  curvature  of  the  stomach,  hardly  large  enough 
to  be  denominated  a  tumor,  but  which  had  thoroughly 
implanted  itself,  and  was  making  rapid  headway.  It  was 
removed,  and  at  present  she  is  enjoying  comparatively  good 
health. 

LATE  MALIGNANT  GROWTHS 

These,  especially  in  persons  of  advanced  years,  are  often 
difficult  to  rightly  decide.  In  positive  diagnoses,  where  the 
cachexia  is  marked,  where  the  digestion  is  with  difficulty 


LATE    MALIGNANT    GROWTHS  l6l 

furnishing  adequate  calories,  where  there  are  either  patent 
metastases  or  reasonable  suspicion  of  their  presence,  the 
internist  should  be  cautious  in  advising  any  radical  opera- 
tion with  the  hope,  implied  or  expressed,  of  lengthened  days. 
While  at  best  the  outlook  is  dark  for  these  sufferers,  surgery 
of  any  sort  seldom  brightens  it. 

In  such  gloomy  conditions,  I  often  lay  before  the  patient 
in  as  tactful  a  manner  as  possible  both  sides  of  the  question, 
advising  him  to  also  discuss  the  situation  thoroughly  with  a 
competent  surgeon,  and  permit  him  or  the  responsible 
members  of  the  family  to  make  the  decision. 

About  one  year  ago,  there  came  under  my  observation  a 
lady  of  forty-eight,  who,  four  years  previously,  had  had  her 
left  ovary  removed,  and  her  right  kidney  suspended.  The 
kidney  promptly  became  loose  again.  She  had  a  suggestive 
family  history,  her  mother  and  her  two  sisters  having  died 
from  uterine  cancer. 

She  was  extremely  cachectic,  had  lost  much  weight,  had 
decided  anorexia,  and  complained  of  a  dtill  but  constant 
pain  in  her  stomach.  Palpation  revealed  a  tender  and  in- 
durated growth  occupying  apparently  the  whole  of  the 
greater  curvature  of  the  stomach. 

An  X-ray  picture  showed  a  jagged,  irregidar  greater 
curvature,  and  obliteration  of  the  "duodenal  cap";  also  a 
decided  six-hour  residue. 

A  test  of  her  stomach  contents  disclosed  no  free  hydro- 
chloric acid,  positive  occult  blood,  lactic  acid,  and  Boas- 
Oppler  bacilli  in  abundance. 

The  diagnosis  of  malignancy  being  positive,  the  question 
at  once  arose  whether  or  not  the  case  was  strictly  surgical. 

Knowing  that,  upon  operation,  a  gastric  tumor  generally 
proves  larger  than  the  palpating  fingers  would  indicate, 
and  noting  her  rapidly  deepening  cachexia,  I  hesitated 
urging  upon  her  an  operation  which  my  better  judgment 
said  would  be  futile.  On  the  contrary,  realizing  human 
fallibility,  I  could  not  dissuade  her  from  taking  the  only 
chance,  though  desperate,  that  lay  open  to  her. 


1 62  IS   THE    CASE    STRICTLY    SURGICAL? 

Under  these  circumstances  I  rather  left  it  with  her  and 
an  intelligent  sister,  and  they  consulted  a  surgeon,  who 
insisted  that  a  speedy  operation  was  indicated,  intimating 
that  my  hesitation  was  quite  uncalled  for. 

She  elected  to  have  her  abdomen  opened,  but  exploration 
showed  an  inoperable  growth. 

In  her  reduced  state,  she  never  fully  reacted,  living  less 
than  ten  days. 

NON-MALIGNANT  GROWTHS  OF  THE  STOMACH, 
PYLORUS  OR  DUODENUM 

In  some  of  these  cases,  surgery  wins  its  brightest  laurels. 
When  the  patient  is  comparatively  young,  when  there  is 
little  or  no  cachexia,  but  where  the  symptoms  point  to 
plain  obstruction  from  cicatricial  growth,  surgery  should  be 
sought  without  hesitation. 

Drs.  Max  Einhorn  and  J.  W.  Weinstein,  of  New  York, 
recently  informed  me  that  in  their  opinion,  the  presence 
of  a  marked  seven-hour  residue  in  the  stomach,  after  a 
fairly  liberal  meal,  called  for  surgery  in  nearly  every 
instance. 

Where  the  pyloric  outlet  is  greatly  stenosed,  it  is  useless 
for  the  internist  to  continue  medical  treatment,  with  the 
expectation  of  notable  improvement,  though  some  of  the 
symptoms  may  be  ameliorated  for  a  season. 

Again,  there  are  occasionally  sudden  and  acute  kinks  of 
the  duodenum,  which,  for  a  time,  as  effectually  close  the 
pyloric  outlet  as  if  a  growth  were  there. 

Eight  months  ago,  I  saw  a  physician  of  thirty-five  years, 
who  was  in  extremis  from  inanition.  When  his  stomach 
became  overdistended,  he  would  simply  let  it  overflow,  and 
then  would  ravenously  call  for  more  food  or  drink. 

An  acute  kink  of  the  duodenum,  brought  about  byja 
ptosed  stomach  was  diagnosed,  and  his  head  was  lowered, 
his  body  and  feet  being  elevated  to  an  angle  of  about 
45    degrees.     The   vomiting    at    once    ceased,    he    readily 


ATONY    AND    DILATATION    OF    STOMACH  1 63 

retained  nourishment,  and  he  was  kept  in  this  position  for 
nearly  a  week,  when  he  was  thought  strong  enough  for 
surgical  intervention.  His  stomach  was  suspended  by 
Dr.  E.  G.  Jones  and  from  that  day  to  this,  he  has  never 
suffered  a  digestive  qualm,  having  gained  about  60  pounds. 

CONFIRMED  ATONY  AND  DILATION  OF  THE 
STOMACH 

Sometimes  these  cases  need  to  come  to  surgery,  but  often 
a  better  result  may  be  accomplished  by  other  means. 

Extensive  adhesions  and  constrictions  of  the  bowels, 
with  marked  visceroptosis  are  sometimes  quite  a  problem. 

Massage,  abdominal  supports,  hydrotherapy,  electricity, 
etc.,  are  in  many  cases  sufficient  to  bring  on  such  a  state  of 
comparative  relief  that  surgery  need  not  be  recommended. 
Occasionally,  however,  this  offers  the  only  tangible  aid. 

An  extremely  small  woman  consulted  me  some  months 
ago  for  obstinate  constipation,  coupled  with  lancinating 
pains  at  every  act  of  defecation.  She  was  found  to  have  a 
general  ptosis  of  all  the  abdominal  viscera,  her  intestines 
seeming  to  be  inextricably  twisted  together  in  her  pelvis. 

Possessing  ample  means,  she  had  employed  every  known 
measure  except  operative,  and,  even  in  her  sad  condition, 
she  submitted  to  the  operation  with  reluctance.  The 
procedure  was  entirely  successful,  and  her  bowels  soon 
began  moving  naturally  and  effectually,  just  as  soon  as 
the  many  and  tortuous  kinks  were  rectified. 

APPENDICITIS,  ACUTE  OR  RELAPSING 

There  are  probably  no  inflammatory  conditions  of  any 
sort  in  the  abdominal  cavity,  which  tax  the  discriminating 
judgment  of  the  internist  as  do  the  various  appendiceal 
manifestations.  Were  it  always  possible  to  immediately 
place  the  patient  in  a  hospital,  where  he  could  be  under  the 
constant  scrutiny  of  practised  eyes;  where  frequent  leuco- 


164  IS    THE    CASE    STRICTLY    SURGICAL? 

cyte  counts  could  be  made  by  competent  microscopists ; 
and  where  trained  abdominal  surgeons  were  ready  at  a 
moment's  notice,  the  problem  would  be  greatly  simplified. 

Unfortunately,  the  majority  of  acute  appendicites  occur 
in  those  who,  of  necessity,  must  depend  on  the  judgment  of 
the  general  practitioner,  and  who  find  themselves  in  that 
dangerous  channel  between  the  Scylla  of  surgery  and  the 
Charybdis  of  delay. 

Let  me  affirm  that  but  few  cases,  unless  they  be  of  the 
fulminating  type,  require  operative  interference  during  the 
first  attack.  In  this  opinion  many  surgeons  will  not  con- 
cur. Furthermore,  if  all  of  the  facilities  above  mentioned 
are  available,  the  attending  physician  can  better  afford  to 
await  developments,  than  in  a  case  in  some  isolated  locality, 
where  delay  might  force  a  hurried  operation  by  inexperi- 
enced hands,  or  might  necessitate  a  journey  to  a  city, 
coupled  with  all  the  dangers  incident  to  the  moving  of  a 
patient  in  such  a  precarious  condition. 

Let  me  lay  down  a  few  general  rules  to  be  considered,  no 
one  of  which  can  be  taken  too  literally. 

If  it  is  possible  to  have  frequent  blood  counts  made,  the 
result  will  be  helpful,  but  not  necessarily  conclusive.  If 
the  differential  count  is  not  marked  and  does  not  increase, 
but  rather  diminishes,  and  the  symptoms  gradually  defer- 
vesce,  an  operation  during  the  acute  attack  is  probably  not 
indicated. 

Dr.  E.  E.  Smith  has  shown  that  the  differential  blood 
count  is  an  indicator  of  the  activity  of  the  process  and  not 
invariably  of  gangrene;  but  if  the  absolute  leucocytosis  is 
low  (below  15,000),  with  high  polynuclears,  it  is  probably 
gangrene. 

Dr.  Charles  Langdon  Gibson  holds  that  the  greater  the 
disproportion,  the  surer  are  the  findings,  and  in  extreme 
disproportions  the  method  has  proved  itself  practically 
infallible.  As  the  relative  disproportion  between  the  leu- 
cocytosis and  the  percentage  of  the  polynuclear  cells  is  of  so 
much  more  value  than  the  findings  based  on  the  leucocyte 


APPENDICITIS  165 

count  alone,  this  latter  method  should  carry  more  weight 
when  performed  by  a  competent  microscopist. 

Dr.  George  H.  Noble  has  well  said,  however,  that  the 
differential  blood  count  is  only  one  among  many  other 
factors  in  determining  as  to  the  surgical  indications,  and 
too  much  stress  should  not  be  accorded  it  alone. 

If  the  patient  shows  decided  symptoms  of  acute  peritoni- 
tis when  first  seen,  or  they  come  on  suddenly,  with  marked 
general  muscular  rigidity,  exquisitely  tender  abdomen, 
tympanites,  with  drawn  and  anxious  features,  an  opera- 
tion is  urgently  indicated. 

If  there  be  found  on  careful  palpation  an  area  of  resist- 
ance in  the  right  iliac  fossa,  and  this  increases  along  with 
the  general  symptoms  for  twelve  hours,  especially  with 
slight  chilly  sensations,  an  operation  is  indicated. 

If  there  is  a  disproportion  of  the  pulse  rate  with  the  tem- 
perature— either  a  rising  temperature  with  a  slow  pulse,  or 
a  normal  or  sub-normal  temperature  with  a  rising  pulse 
rate,  an  operation  is  probably  indicated. 

Should  there  be  symptoms  of  abscess  or  should  the  case 
not  improve  in  a  few  days,  with  the  suspicion  of  complica- 
tions, an  operation  is  probably  indicated. 

If  even  there  is  diminishing  tenderness  in  the  abdomen, 
with  normal  temperature  and  pulse,  but  the  patient's  facial 
expression  is  drawn  and  pinched,  while  an  indefinite  sense 
of  ill-being  is  constantly  present,  the  internist  had  best 
keep  in  touch  with  a  surgeon,  for  appendicitis  is  one  of  the 
most  treacherous  of  diseases,  and  some  symptom  of  fatal 
import  may  appear  at  any  time  with  kaleidoscopic  rapidity. 

Should  the  first  attack  pass  over  in  safety,  no  operation 
is  called  for  unless  the  trouble  shows  a  tendency  to  recur. 
If  the  second  attack  is  milder  than  the  first,  delay  may  be 
allowed,  but  if  the  exacerbations  are  inclined  to  increase  in 
severity  or  frequency,  an  interval  operation  is  highly 
advisable,  lest  the  patient  be  suddenly  stricken  when 
surgical  aid  is  not  promptly  available. 

These  general  suggestions  cannot  take  the  place  of  sound 


1 66  IS    THE    CASE    STRICTLY    SURGICAL? 

and  discriminating  judgment,  which  must  be  exercised  in 

every  instance,  whereby  each  case  is  decided  on  its  own 

merits,    after    conscientiously  weighing    every    symptom, 
for  and  against. 

GASTRIC  OR  DUODENAL  ULCER 

Some  of  these  cases  come  to  surgery  after  internal  treat- 
ment has  proved  unavailing.  As  to  whether  a  chronic  ulcer 
in  the  stomach  or  duodenum  should  be  given  up  by  the 
internist,  depends  greatly  upon  the  intelligence  and  mental 
attitude  of  both  the  patient  and  physician. 

Should  the  patient  willingly  submit  to  thorough  and  ade- 
quate treatment,  allowing  plenty  of  time  for  Nature's 
recuperative  work,  and  submitting  with  equanimity  to 
the  probably  rigorous  measures  indicated,  the  chances 
for  a  cure  are  fairly  bright;  and,  if  proper  dietetic  and 
hygienic  precautions  are  faithfully  adhered  to,  the  dangers 
of  a  relapse  are  proportionately  lessened. 

If,  on  the  contrary,  the  patient  is  high-strung  and  irri- 
table, with  perhaps  bad  habits,  and  no  special  pertinacity 
in  following  out  a  set  course ;  if  he  claims  pressing  business 
engagements  that  will  infringe  on  the  time  needed  for  his 
treatment,  trying  to  force  the  physician  to  make  unreason- 
able promises,  as  has  often  occurred  in  my  experience;  and 
if  the  case  gives  a  history  of  frequent  relapses  after  longer 
or  shorter  periods  of  comparative  health,  with  some  indi- 
cations of  impaired  gastric  motility,  or  pyloric  patency,  the 
internist  should  be  most  cautious  in  holding  out  assurances 
of  permanent  improvement,  except  through  surgical  means. 

Many  of  these  "ulcer  cases"  habitually  go  from  one 
internist  to  another,  seeking  relief,  but  they  are  unwilling  to 
furnish  the  time,  patience  and  co-operation,  which  should 
balance  the  science,  thought  and  forbearance  required  of 
the  physician,  consequently  nothing  tangible  or  lasting  is 
accomplished. 

Such  as  these  are  best  referred  to  the  surgeon  at  once, 


HEMORRHAGES    FROM    THE    STOMACH  1 67 

for  to  the  internist,  they  are  simply  "a  weariness  and 
vexation  of  spirit,"  adding  nothing  to  either  his  reputation 
or  purse,  and  demanding  much  valuable  time  that  could  be 
better  spent  with  more  hopeful  conditions. 

HEMORRHAGES  FROM  THE  STOMACH  OR 
UPPER  ALIMENTARY  TRACT 

No  hemorrhage  from  the  body  is  more  dramatic  or  excit- 
ing than  from  the  stomach,  when  there  well  up  quantities 
of  dark,  grumous  blood.  Fortunately  the  first  hemate- 
mesis  is  seldom  fatal,  and  only  when  there  are  frequent 
repetitions,  is  surgery  required. 

Were  it  certain  that  the  blood  came  from  one  or  perhaps 
only  a  few  frankly  bleeding  spots,  the  situation  would  be 
different.  Often,  however,  there  are  multiple  erosions,  or 
even  a  deeply  congested  gastric  mucosa  from  which  the 
blood  oozes  in  countless  minute  streams.  Apart  from  clear- 
ing out  the  coagula,  so  as  to  permit  of  gastric  contraction, 
and  the  use  of  direct  astringent  measures,  surgery  can  do 
but  little  in  these  fulminant  cases.  Furthermore,  what  is 
done,  must  be  done  quickly  and  expertly,  and,  unless  the 
patient  can  be  placed  in  the  hands  of  one  absolutely  skilled 
in  abdominal  surgery,  with  trained  assistants  and  every 
possible  facility,  I  would  certainly  hesitate  at  advising 
any  patient  to  have  his  abdomen  opened  up  for  a  gastric 
hemorrhage. 

This  conclusion,  which  will  probably  not  be  accepted  by 
some  estimable  surgeons,  has  been  forced  upon  me  by  some- 
what extended  observations. 

CHRONIC  AND  INDEFINITE  ILLS  THAT  HAVE 
RESISTED  ALL  INTERNAL  TREATMENT 

This  may  include  a  heterogeneous  mass  of  "old  and  expe- 
rienced invalids,"  who  are  really  ill,  and  whose  digestive 
discomforts  arise  from  material  causes. 

Sometimes  an  exploratory  laparotomy  will  disclose  the 


1 68  IS   THE    CASE    STRICTLY    SURGICAL? 

chief  lesion,  and  perhaps  point  the  way  to  an  absolute  cure. 
Again,  the  necessary  quietude  and  rest  to  the  abdomen  and 
alimentary  tract  following  an  operation  will  often  exert  a 
far-reaching  good  effect,  augmenting  many -fold  the  actual 
benefit  conferred  by  the  surgical  procedure.  I  might  men- 
tion, also,  that,  even  when  nothing  of  consequence  is  done 
by  the  surgeon,  the  operation  itself,  with  the  opening  of 
the  abdominal  cavity,  may  put  into  action  the  most  mar- 
velous train  of  psychic  sensations,  and  an  apparently  per- 
manent improvement  ensues. 

Two  years  ago,  a  lady  of  forty-five  came  under  my  care 
for  stricture  of  the  intestines,  non-malignant  in  character. 
Thinking  that  perhaps  the  one  or  more  strictures  were  close 
enough  together  to  permit  of  a  resection,  I  advised  an  opera- 
tion, and  the  abdomen  was  opened  by  Dr.  E.  C.  Davis. 
Inspection  showed  extensive  strictures  situated  at  short 
intervals  throughout  probably  lo  or  15  feet  of  the  small 
intestines,  rendering  resection  impracticable.  The  abdo- 
men was  closed,  and  the  patient  put  back  to  bed.  The 
recovery  from  the  laparotomy  was  uneventful,  but  she 
complained  no  more  of  the  terrific  cramps,  which  before 
were  the  bane  of  her  existence.  Her  intestines  were  kept 
distended  by  agar  agar,  and  freely  lubricated  by  olive  oil 
and  liquid  albolene,  so  that  she  had  fairly  satisfactory  fecal 
movements  daily.  She  soon  began  to  brighten  up,  to  take 
an  interest  in  affairs  of  life,  to  eat  heartily  and,  with  it  all, 
developed  a  cheerful,  optimistic  frame  of  mind  that  kept  her 
happy  and  contented. 

With  the  exception  of  a  marked  tendency  to  constipation, 
which  she  overcomes  by  constant  care,  she  is  at  this  time  a 
fairly  normal  woman.  She  was  never  informed  as  to  what 
was  not  done  in  her  abdomen,  and  to  this  day  she  considers 
herself  a  living  monument  to  surgical  achievement. 

So,  after  all  known  medical  and  internal  means  have  been 
exhausted  without  avail,  it  may  be  well  to  suggest  to  have 
the  abdomen  thoroughly  explored,  with  the  hope  of  Micaw- 
ber  that  "something  may  turn  up  "  that  can  be  remedied. 


IS   THE   CASE    STRICTLY   SURGICAL?  1 69 

We  should  remember,  however,  that  there  are  surgeons 
and  surgeons,  and,  unless  it  is  practicable  for  our  patients  to 
command  the  services  of  those  adept  in  surgery  of  the  abdo- 
men, we  should  be  quite  slow  to  recommend  radical  meas- 
ures with  the  implied  hope  of  marked  improvement  or  cure. 
Otherwise,  we  might  suggest  to  our  long-suffering  dyspep- 
tics that  perhaps  it  would  be  preferable  to  "bear  those  ills 
they  have,  than  fly  to  others  that  they  know  not  of." 


CHAPTER  VI 
THE  STOMACH-TUBE 

Although  there  were  some  random  attempts  to  explore 
the  stomach  by  the  use  of  a  tube  before  the  days  of  Kuss- 
maul,  it  was  he,  who  in  1867  first  inaugurated  intelligent 
and  systematic  methods.  In  187 1  Leube  also  began  to 
demonstrate  its  use,  and  to  these  two  notable  men  we  owe 
much  of  our  present-day  knowledge  concerning  this  useful 
diagnostic  and  therapeutic  instrument. 

Unfortunately,  the  prevailing  attitude  of  the  public 
toward  the  stomach-tube  is  anything  but  favorable — in 
many  instances  amounting  to  an  actual  repugnance.  I 
have  known  many  patients,  who  have  spent  sleepless  nights 
in  awesome  anticipation  of  the  trying  ordeal,  and  others, 
who  would  suffer  for  months,  rather  than  submit  to  what 
they  considered  a  horrible  torture.  So  often  do  I  hear  some 
intelligent  patient  say — "Doctor,  I  would  have  been  to 
you  for  aid  long  ago,  had  I  not  dreaded  to  take  that  awful 
stomach-tube." 

The  reason  for  this  is  not  hard  to  find.  It  lies  in  the 
careless,  inexpert,  or  principally  slow  technic  of  those  who 
have  introduced  the  tube,  and  have  inflicted  upon  patients 
such  needless  discomfort,  that  they  have  not  only  become 
themselves  prejudiced,  but  have  spread  abroad  the  evil 
tidings.  Candidly,  I  cannot  blame  them,  and  it  is  the  duty 
of  the  physician  of  this  day  to  learn  how  to  introduce  a  tube 
so  deftly  that  this  prejudice  will  be  overcome. 

There  are  certain  contraindications  to  the  employment  of 
the  stomach-tube,  and  these  I  will  first  make  plain: 

(i)  Pregnancy,  especially  if  advanced  beyond  the  fifth 
month.  The  first  few  months  should  make  no  difference, 
and  even  the  later  months,  if  the  patient  is  accustomed  to 

170 


CONTRAINDICATIONS    TO    STOMACH    TUBE  171 

the  tube*  and  the  operator  is  expert.     If,  however,  the  pa- 
tient has  not  taken  the  tube  before,  the  risk  is  grave. 

Several  years  ago  in  a  New  York  cHnic  I  saw  a  tube  intro- 
duced into  the  stomach  of  a  Jewish  woman  apparently 
eight  months  pregnant.  She  struggled  violently,  and  when 
she  arose  there  was  about  half  a  pint  of  amniotic  fluid  in  the 
bottom  of  the  chair. 

(2)  Organic  heart  disease  with  broken  compensation. 
To  this  may  be  added  so-called  cardiac  neuroses,  angina 
pectoris,  real  or  pseudo,  myocarditis,  or  any  condition 
where  the  heart  seems  decidedly  below  par. 

In  some  of  these  conditions,  where  the  cardiac  lesion 
does  not  appear  to  be  acute,  if  the  patient  is  quite  phleg- 
matic, or  if  the  operator  is  expert,  a  risk  may  be  taken, 
but  the  physician  should  realize  that  it  is  somewhat  of  a 
risk. 

(3)  Aneurysm  of  any  of  the  large  arteries.  This  condi- 
tion absolutely  contraindicates. 

(4)  Recent  hemorrhages  of  any  kind.  This  heading  may 
include  hemorrhage  from  the  stomach,  intestines,  lungs, 
bladder,  uterus,  apoplexies,  or  hemorrhagic  infarctions. 

A  fairly  good  rule  is  to  permit  from  ten  days  to  two  weeks 
to  elapse  after  one  of  these  hemorrhages,  before  attempting 
to  pass  the  stomach-tube. 

(5)  Advanced  puhnonary  tuberculosis,  or  advanced 
pulmonary  emphysema  with  bronchitis.  The  evident  con- 
dition of  the  patient  in  these  advanced  pathologic  states 
will  generally  show  the  inadvisability  of  attempting  to 
pass  a  tube. 

(6)  Advanced  arterio-sclerosis.  The  tube  is  generally 
contraindicated  in  these  cases,  whether  or  not  the  blood 
pressure  is  abnormally  high.  Even  under  the  most  favor- 
able psychic  conditions,  they  seldom  take  the  tube  kindly, 
and  it  is  seldom  wise  to  attempt  it — especially  if  the  blood 
pressure  is  high. 

(7)  Advanced  cachexia  from  any  cause.  In  some  of 
these  extremely  enfeebled  states,  any  manipulation  entail- 


172  THE    STOMACH-TUBE 

ing  the  slightest  shock  may  turn  the  scales  unfavorably, 
and  the  introduction  of  the  tube  should  not  be  attempted, 
unless  for  very  strong  reasons. 

(8)  Evidences  of  erosions  of  the  gastric  mucosa,  either 
malignant  or  non-malignant.  In  this  may  be  included 
palpable  carcinoma  of  the  stomach  or  pylorus,  accompanied 
by  vomiting  of  coffee-ground  material.  These  symptoms 
being  present,  the  introduction  of  a  tube,  no  matter  how 
carefully  performed,  may  cause  serious  damage.  It  is 
unwise  also  to  explore  the  stomach  with  a  tube  when  there 
are  strong  indications  of  either  a  single  open  ulcer  or  mul- 
tiple erosions,  even  though  they  be  shallow. 

(9)  Acute  febrile  conditions.  All  of  these  may  not 
constitute  a  bar  to  the  use  of  the  tube,  but  the  operator  will 
find  these  patients  very  unresponsive,  and,  unless  great 
benefit  is  likely  to  be  accomplished,  he  will  find  that  more 
discomfort  is  inflicted  than  good  is  accomplished. 

(10)  Those  rare  and  peculiar  conditions,  where  upon  the 
slightest  touch  of  the  tube  against  the  epiglottis  the  larynx 
spasmodically  closes,  and  the  patient  becomes  blue. 
These  conditions  have  not  been  explained,  but  they  occa- 
sionally are  in  evidence,  and  must  be  taken  into  account. 
This  does  not  mean  those  nervous,  struggling  patients,  who 
vow  they  are  choking,  when  they  are  not,  and  who  need  only 
to  exercise  self-control.  It  means  those  who,  in  calmness 
try  faithfully  and  intelligently  to  swallow  the  tube,  but 
whose  whole  respiratory  machinery  automatically  closes 
upon  the  slightest  touch  of  the  tube,  while  the  face  becomes 
livid,  if  the  effort  is  continued.  These  individuals  simply 
possess  an  idiosyncrasy  against  the  tube,  and  it  is  useless 
to  attempt  to  force  it  upon  them. 

(11)  Those  patients,  who  are  violently  nauseated  at  the 
merest  touch  of  the  tube  upon  the  tongue,  epiglottis  or  any 
part  of  the  fauces,  or  who  incline  to  vomit  at  the  sight  or 
mention  of  it.  There  are  some  hyper-sensitive  individuals, 
who  really  seem  in  good  faith  unable  to  bear  the  sight,  men- 
tion or  touch  of  a  stomach-tube,  whose  very  nature  revolts 


CHOICE  OF  STOMACH  TUBE 


173 


against  its  use,  and  who  cannot  help  this  feeling.  I  have 
seen  a  few  such  curious  individuals,  and  can  affirm  that 
scarcely  any  diagnostic  information  will  recompense  the 
physician  for  the  strenuous  efforts  required  to  extract  a 
test-meal  from  their  frenzied  stomachs. 

The  choice  of  a  tube  is  quite  important.  The  size  for  an 
adult  should  vary  from  18  English  or  30  French  to  20  Eng- 
lish or  3  2  French.  Smaller  than  this  renders  the  tube  rather 
small  and  soft.  Larger  numbers  are  used  by  some,  up  to  24 
English,  and  while  an  ordinary  esophagus  can  accommodate 
them  comfortably,  the  size  is  inclined  to  be  alarming.     To 


Fig.  41. — Stomach-tubes.     A,  proper  tube,  large  smooth  eye,  sufficient  caliber; 
B,  improper  tube,  eye  too  small;  C,  improper  tube,  eye  sharp  and  small. 

a  fearful  patient  a  tube  always  looks  really  larger  than  it  is, 
and  if  he  catches  a  glimpse  of  a  "24,"  he  will  probably  be 
unduly  alarmed.  It  is  much  easier  to  use  a  smaller  tube 
than  to  quiet  his  perturbed  feelings. 

For  children,  tubes  may  be  used  as  small  as  1 2  English  or 
2 1  French,  or  best  1 5  English  or  2  5  French.  The  latter  can 
be  inserted  into  the  esophagus  of  a  four-year  old  child,  and 
it  is  rarely  necessary  to  introduce  a  tube  in  a  younger 
patient. 

The  tube  should  be  of  red  rubber,  and  fairly  stiff.  When 
lacking  in  a  certain  amount  of  rigidity,  it  is  liable  to  coil  up 


174  THE    STOMACH-TUBE 

in  the  mouth  instead  of  passing  on  down  the  esophagus,  and 
later  on,  when  the  esophageal  muscles  or  the  cardiac  open- 
ing of  the  stomach  are  resenting  its  onward  progress,  it  is 
liable  to  "buckle,"  to  the  discomfort  of  the  patient  and  the 
inconvenience  of  the  physician.  The  use  of  a  wire  or  any 
other  appliance  to  stiffen  the  tube,  I  have  not  found  helpful. 

Up  to  a  few  years  ago,  the  imported  were  much  the  best, 
but  at  present  tubes  can  be  obtained  in  America,  fashioned 
and  moulded  to  suit  the  most  fastidious. 

In  regard  to  the  number,  size  and  character  of  the  open- 
ings of  the  lower  end  of  the  tube  there  is  some  difference  in 
opinion,  though  all  unite  in  condemning  that  abomination, 
the  tube  with  a  sharp-edged  opening  in  the  center  of  the 
end.  There  is  no  estimating  the  damage  done  to  delicate 
gastric  mucosae  by  these  dangerous  tubes,  and  such  should 
never  be  employed.  Some  advocate  tubes  with  from  three 
to  eight,  or  even  more  openings  near  the  end  for  the  extrac- 
tion of  test-meals.  In  my  experience,  however,  I  have 
obtained  the  best  results  from  a  tube  with  two  openings,  one 
about  half  an  inch  above  the  other  and  on  the  opposite 
side  of  the  tube.  These  openings  should  be  of  "velvet 
finish,"  so  as  to  inflict  no  injury  to  the  mucosa,  should  it  be 
drawn  into  the  openings  by  force  of  aspiration.  The  end 
of  the  tube  should  be  closed,  smooth  and  round. 

Lavage  tubes  should  possess  from  two  to  five  openings, 
though  I  consider  five  about  the  proper  number.  Where 
the  tube  is  to  be  used  in  an  empty  stomach,  a  great  number 
of  very  small  openings  is  feasible;  but  generally  there  are 
remnants  of  food  or  shreds  of  mucus  to  be  removed  through 
the  tube,  and  then  the  small  openings  are  unsatisfactory. 

As  a  general  rule  the  lavage  tube  should  be  a  little  larger 
than  the  one  for  extracting  a  test-meal.  In  the  first  place, 
more  room  is  required  successfully  to  clean  the  stomach, 
and  besides,  the  patient  has  learned  more  about  the  tube 
and  can  be  induced  to  swallow  a  larger  one  without  serious 
objection.  Judgment,  though,  must  at  all  times  be  exer- 
cised in  the  choice  of  size  to  be  employed. 


EXTRACTION    OF    TEST-MEAL  1 75 

For  lubricating  the  tube  plain  water  is  by  far  the  best. 
Glycerin,  oils  of  various  sorts,  cream  and  a  host  of  other 
agents  have  been  advocated,  only  to  be  discarded.  The 
supremacy  of  water  admits  of  no  argument. 

Many  efforts  have  been  put  forth  to  render  insensitive  the 
throat  and  fauces.  There  have  been  recommended  a  3 
per  cent,  solution  of  cocaine,  or  a  5  per  cent,  solution  of 
orthoform  to  be  sprayed  over  the  fauces.  Even  a  spray  of 
ether  or  ethyl  chloride  has  been  attempted.  Others  have 
painted  the  throat  and  fauces  with  collodion,  or  a  solution 
of  adrenalin,  or  even  a  5  per  cent,  solution  of  nitrate  of 
silver.  Let  me  deprecate  the  use  of  all  these  methods. 
None  of  them  can  take  the  place  of  skill  and  celerity  in 
introducing  the  tube,  and  none  or  all  of  them  can  atone  for 
the  lack  of  these  attributes  on  the  part  of  the  physician. 

When  the  physician  prepares  to  extract  a  test-meal  from 
a  patient  who  has  never  undergone  the  experience,  he  should 
enter  upon  his  task  with  kindness,  gentleness,  and  patience. 
He  should  spend  several  minutes  in  reassuring  the  patient, 
calming  his  fears,  and  soothing  his  hyper-sensitive  nerves. 
The  doctor  should  inform  him  that  the  information  to  be 
obtained  is  likely  to  prove  of  the  utmost  value  in  diagnosis 
and  subsequent  relief  of  symptoms,  and  that  the  slight 
inconvenience  will  be  more  than  compensated  by  the  insight 
afforded  into  obscure  ills.  The  patient  should  always  be 
interrogated  as  to  false  teeth,  and,  if  worn,  they  should  be 
removed.  This  inquiry  should  never  be  omitted,  for 
occasionally  very  young  persons  have  them,  and  they  are 
fitted  so  naturally,  that  their  presence  is  not  suspected. 

There  are  different  methods  employed  to  protect  the 
patient  and  his  clothing  while  a  test-meal  is  being  extracted, 
some  of  them  most  cumbersome  and  fear-inspiring.  Too 
many  "protectives,"  rubber  aprons,  etc.,  are  not  advisable, 
in  my  opinion,  and  I  have  come  to  use  two  plain  towels, 
one  around  the  neck,  and  one  in  the  lap.  A  plain  wash 
basin  may  be  placed  in  the  lap,  or  a  small  porcelain  basin. 
Too  many  preparations  will  certainly  alarm  the  patient. 


176  THE    STOMACH-TUBE 

Should  there  be  an  assistant  at  hand,  the  patient  need 
only  hold  the  basin,  otherwise  he  is  instructed  to  hold  the 
glass  retainer  in  his  left  hand,  and  the  basin  in  his  right, 
the  operator  admonishing  him  to  hold  on  tightly  to  both, 
and  on  no  account  to  drop  them. 

Up  to  this  time  the  patient  has  not  seen  the  tube,  nor 
should  he  be  permitted  to  see  it  until  the  instant  it  is  to  be 
used.  If  he  has  opportunity  to  gaze  on  it  too  long,  he  may 
refuse  altogether  to  swallow  it. 

Now  as  to  the  actual  method  of  introducing  this  tube: 
I  realize  that  the  methods  are  legion,  and  that  some  opera- 
tors get  satisfactory  results  by  means  that  would  give  no 
results  whatever  to  others. 

I  will  briefly  mention  some  of  these  methods,  and  then 
give  in  detail  the  one  that  has  proved  the  best  in  my  hands. 

Dr.  Max  Einhorn  stands  directly  in  front  of  the  patient, 
tells  him  to  open  his  mouth,  presses  down  the  tongue  with 
two  fingers  of  his  left  hand,  puts  in  the  tube,  and  has  it  in 
the  stomach  in  an  incredibly  short  space  of  time.  This 
answers  in  Dr.  Einhorn 's  skilled  hands,  but  would  not  in 
one  less  practised,  for  there  is  nothing  to  prevent  the 
patient  from  pulling  back  and  escaping  from  the  tube,  if 
he  so  desired. 

Others  stand  either  in  front  of  the  patient,  or  slightly  to 
the  left,  and  attempt  to  start  the  introduction  of  the  tube 
at  the  proper  place  by  the  aid  of  sight,  as  the  mouth  is 
widely  opened.  This  has  proved  a  poor  way,  for  here  again 
the  physician  has  but  little  control  of  the  patient,  who, 
with  his  mouth  wide  open  and  his  head  thrown  back,  is 
more  apt  to  be  nauseated  than  when  his  mouth  is  nearly 
closed. 

The  best  way  is  to  stand  at  the  right  of  the  patient,  with 
the  left  arm  of  the  physician  lightly  placed  around  the 
neck,  and  the  left  hand  in  front  of  the  mouth  so  as  to  guide 
and  control  the  tube.  Asking  the  patient  to  slightly  (not 
widely)  open  his  mouth,  the  tube  is  gently  but  quickly 
inserted  between  the  lips,  and  pressed  back  against  the 


EXTRACTION    OF   TEST-MEAL  1 77 


Fig.  42. — Correct  position  of  operator  and  patient  for  introduction  of  stomach- 
tube. 


EXTRACTION    OF    TEST-MEAL  1 79 

epiglottis.  This  is  done  by  the  right  hand  of  the  operator, 
while  the  tube  runs  between  and  is  steadied  by  the  two 
fingers  of  his  left  hand  that  are  directly  over  the  patient's 
mouth.  The  patient  is  then  gently  asked  to  swallow,  and 
the  gentle  injunction  is  repeated  several  times  until  he 
makes  the  effort  to  swallow.  Just  as  he  does  this,  the  tube 
will  slip  by  the  epiglottis  and  down  the  esophagus — not 
the  larynx,  for  it  is  almost  an  impossibility  for  the  tube  to 
penetrate  there.  Should,  at  this  instant,  the  patient 
complain  of  choking,  admonish  him  to  swallow  again,  and 
when  he  finds  he  can  do  so,  he  will  have  no  fear.  In  the 
meantime  the  tube  is  being  rapidly  propelled  down  the 
esophagus,  and  generally  a  little  sound  of  escaping  gas  can 
be  detected  as  the  tube  slips  through  the  cardiac  orifice. 

Ordinarily  a  distance  of  20  or  21  inches  will  put  the  tube 
sufficiently  into  the  stomach,  but  there  are  many  variations 
to  this  rule.  Tall  patients,  or  those  with  prolapsed  stom- 
achs will  require  more  inches,  while  I  have  had  diminutive 
patients  whose  stomach  cavities  were  but  little  over  18 
inches  from  the  teeth. 

I  well  remember  one  tall  and  slender  old  lady,  with  re- 
laxed abdominal  parietes  and  a  stomach  ptosed  practically 
into  her  pelvis,  who  required  nearly  30  inches  of  tube  in 
order  to  either  aspirate  or  irrigate  her  stomach. 

At  this  time  the  patient  should  sit  erect,  with  the  head 
slightly  inclined  forward,  as  this  position  minimizes  the 
nausea.  This  may  require  some  reminding  or  gentle 
urging,  for  nearly  every  one  under  the  circumstances,  is 
inclined  to  lean  back,  with  the  head  thrown  still  further 
back,  and  the  mouth  wide  open,  all  of  which  tends  to  aug- 
ment instead  of  decrease  the  discomfort. 

It  is  well  at  the  very  first  to  introduce  the  tube  just  a 
little  further  than  is  necessary,  so  as  to  permit  of  gradually 
drawing  it  out  during  the  aspiration,  should  the  end  of  the 
tube  not  engage  itself  in  the  stomach  contents  at  once. 

As  to  the  methods  of  aspirating  the  contents,  they,  too, 
are  legion. 


l8o  THE    STOMACH-TUBE 

The  "expression  method"  consists  of  directing  the  patient 
to  place  his  hands  over  his  stomach,  and  with  both  external 
pressure  and  abdominal  contraction,  as  in  the  effort  to 
empty  the  intestines,  the  contents  of  the  stomach  may  be 
forced  out  of  the  tube.  This  is  a  good  method  when  it 
succeeds,  but  it  rarely  succeeds,  and  moreover  entails  too 
much  effort  on  the  patient's  part. 

Others  use  a  large  Politzer  bag,  aspirating  the  contents 
into  this  bag.  The  objection  to  this  lies  in  the  fact  that 
the  operator  cannot  know  how  much  of  the  contents  he 
has  obtained,  and  also,  if  he  is  not  careful,  he  is  liable,  as  he 
squeezes  the  bag,  to  force  the  contents  back  into  the  stom- 
ach as  fast  as  he  aspirates  them  out. 

By  far  the  best  method  in  my  hands  is  the  simple,  valve- 
less  bulb,  known  as  the  Lockwood  bulb,  and  furnished  by 
Tieman  &  Co.,  of  New  York.  This  is  made  of  good  rubber, 
is  highly  resilient,  and,  possessing  no  valves,  either  end  can 
be  inserted  into  the  end  of  the  tube.  In  aspirating  the 
stomach  contents,  the  bulb  is  compressed  and  one  of  the 
operator's  fingers  is  placed  over  the  open  end,  acting  as  a 
valve.  The  pressure  being  quickly  removed  from  the  bulb, 
it  expands  and  reassumes  its  form,  creating  a  vacuum,  and 
drawing  up  the  contents  of  the  stomach.  The  finger  is 
then  removed  from  the  end,  and  the  next  pressure  empties 
the  contents  of  the  bulb  into  the  waiting  receptacle.  This 
can  be  rapidly  repeated,  and  any  operator  can  soon  acquire 
the  "knack."  Should  the  tube  seem  clogged,  by  placing 
the  finger  over  the  open  end,  and  quickly  compressing  the 
bulb,  air  is  forced  through  the  tube,  and  the  obstruction 
easily  cleared. 

Should  the  efforts  at  aspiration  fail  to  bring  anything,  it 
is  well  to  gently  and  slowly  draw  forward  the  tube,-  while 
these  efforts  are  kept  up,  as  sometimes  the  end  of  the  tube 
is  not  in  the  fluid  contents  at  the  most  dependent  part  of 
the  stomach.  Should  it  be  drawn  on  out  until,  by  the  easy 
escape  of  air,  the  operator  knows  that  the  tube  has  almost 
left  the  stomach,  it  may  be  pressed  downward  again,  and 


EXTRACTION    OF    TEST-MEAL 


ISI 


Fig.  43. — Aspiration  of  stomach  contents. 


EXTRACTION    OF    TEST-MEAL  1 83 

the  same  manipulation  repeated.  This  may  be  done  sev- 
eral times  until  either  the  efforts  are  successful  or  the  oper- 
ator is  convinced  that  the  stomach  is  empty. 

Occasionally  in  stomachs  of  irregular  conformation,  the 
contents  are  extremely  hard  to  locate,  and  it  will  require 
considerable  patience  on  the  part  of  the  physician  to  guide 
the  end  of  the  tube  into  the  small  space  where  it  may  be- 
come engaged.  Intelligent  effort,  however,  assisted  by  for- 
bearance and  co-operation  on  the  part  of  the  patient,  will 
nearly  always  result  in  success. 

In  cases  of  very  patulous  pylorus,  or  hypermotility  of  the 
stomach,  the  viscus  may  be  absolutely  empty,  and  of  course 
efforts  at  aspiration  will  be  futile. 

It  is  seldom  necessary  to  attempt  to  thoroughly  evacuate 
the  stomach  when  getting  a  test -meal.  From  15  to  20 
c.c.  are  sufficient  for  any  ordinary  quantitative  tests,  and 
it  is  not  wise  to  needlessly  prolong  the  operation.  Under 
favorable  circumstances,  from  two  to  four  expansions  of 
the  bulb  will  aspirate  this  quantity  and  then  the  tube  should 
be  rapidly  drawn  from  the  stomach  with  one  gentle  but 
firm  pull.  The  two  fingers  of  the  operator  that  grasp  the 
tube  should  also  compress  it,  so  that  no  random  drops  of 
fiuid  may  run  out  on  the  floor  or  clothing  of  the  patient  as 
it  emerges  from  the  mouth.  This  little  precaution  is  worth 
noting. 

Though  considerable  space  has  been  taken  in  describing 
these  various  manipulations,  the  act  of  introducing  a  tube 
into  a  patient's  stomach,  aspirating  a  test-meal,  and  with- 
drawing the  tube  should  require  but  a  few  seconds.  I  have 
many  times  completed  the  whole  act  in  from  four  to  six 
seconds,  and,  unless  some  hindrance  intervenes,  it  should 
nearly  always  be  completed  inside  of  thirty  seconds.  If 
the  operator  finds  that  it  is  taking  him  longer  than  this,  he 
should  endeavor  to  hasten  the  different  steps,  so  as  to  come 
within  this  time  limit. 

There  is  no  procedure  in  the  whole  range  of  therapeutics 
wherein  deftness  and  celerity  on  the  part  of  the  physician 


184  THE    STOMACH-TUBE 

are  more  appreciated  than  in  the  introduction  of  the 
stomach-tube.  Let  me,  therefore,  urge  my  readers  to 
painstakingly  practise  this  really  simple  operation,  so  that 
the  people  at  large  may  lose  that  fear  and  horror  of  the 
stomach-tube,  and  may,  instead  of  looking  upon  it  as  an 
instrument  of  torture,  accord  it  the  place  it  deserves  as  a 
most  useful  adjunct  in  the  diagnosis  and  treatment  of  dis- 
eases of  the  alimentary  tract. 


CHAPTER  VII 
GASTRIC  LAVAGE 

Among  the  methods  of  treating  the  stomach  locally, 
gastric  lavage  has  held  and  will  necessarily  hold  an  impor- 
tant place.  Since  it  was  first  scientifically  championed  by 
Kussmaul,  the  use  of  this  procedure  has  waxed  and  waned 
through  successive  decades,  until  at  present  it  has  won  its 
proper  and  definite  place;  and,  though  not  universally 
advocated,  is  at  least  respected. 

Like  many  other  somewhat  radical  measures,  gastric 
lavage  has  been  sadly  abused  by  some  of  its  overzealous 
friends,  and  this  abuse  has  built  up  against  it  many  preju- 
dices, some  of  them  founded  upon  just  cause,  which  will 
take  years  to  overcome.  On  the  other  hand,  when  judici- 
ously employed,  under  proper  conditions,  and  with  good 
technic,  it  will  yield  the  most  gratifying  results,  accompan- 
ied by  a  minimum  of  discomfort. 

INDICATIONS  FOR  GASTRIC  LAVAGE 

(i)  In  all  cases  of  poisoning.  Some  clinicians,  with  an 
excess  of  caution,  have  advised  against  the  use  of  this  pro- 
cedure after  the  ingestion  of  acids  or  corrosive  alkalies, 
fearing  that  the  tube  might  perforate  the  eroded  and  weak- 
ened gastric  mucosa.  This  caution  should  be  disregarded, 
for  the  good  to  be  attained  by  washing  from  the  stomach 
the  poison,  before  it  can  be  absorbed  or  sent  onward  into 
the  small  intestine,  will  immeasurably  overbalance  any 
supposed  danger  of  perforation. 

(2)  In  acute  vomiting.  Very  often  a  lavage,  repeated  two 
or  three  times  daily  for  just  a  few  days,  will  exert  an  almost 
magic  effect  in  this  trying  class  of  cases. 

185 


1 86  GASTRIC    LAVAGE 

(3)  In  chronic  gastritis,  with  an  excessive  production 
and  collection  of  mucus  in  the  stomach.  This  statement 
will,  I  am  sure,  excite  dissent  on  the  part  of  some  conscien- 
tious observers.  They  will  point  to  many  patients  who 
have  used  lavage  constantly  for  years  without  apparent 
benefit — perhaps  being  worse  off  than  when  they  began. 
To  these  I  would  admit  that  the  tube  can  be  greatly  abused, 
but  that  in  all  probability  other  factors  were  responsible 
for  the  retardation  of  improvement. 

Gastric  lavage,  with  suitable  astringents,  antifermenta- 
tives,  or  sedatives,  when  employed  not  over  two  or  three 
times  weekly,  I  have  very  many  times  seen  accomplish 
marked  improvement  in  these  conditions,  diminishing 
stomach  distress,  aiding  the  nutrition,  clearing  up  the  skin, 
and  in  other  ways  exercising  a  real  and  tangible  good  effect 
on  the  dyspeptic  and  discouraged  patient. 

(4)  In  dilatation  of  the  stomach  (atonic  type),  with  im- 
paired motor  power,  delayed  evacuation  and  fermentation. 

(5)  In  dilatation  of  the  stomach  (stenotic  type),  with 
motor  insufficiency,  gastritis  and  periodic  vomiting.  In 
no  class  of  cases  is  gastric  lavage  more  fruitful  of  benefit 
than  in  these  two  last  conditions.  I  have  several  times 
seen  patients  in  an  almost  moribund  state,  with  foul, 
fermenting  stomachs  that  had  not  been  emptied  entirely 
for  weeks,  soon  brighten  up,  take  on  renewed  strength,  and 
live  in  comparative  comfort  for  many  months,  principally, 
if  not  entirely,  from  the  benign  effects  of  frequent  and  ade- 
quate lavages  of  their  unclean  stomachs. 

(6)  In  acute  dilatation  of  the  stomach  from  any  cause. 

(7)  In  post-operative  vomiting,  especially  with  reversed 
peristalsis.  Lavage  in  such  conditions  must  be  used  with 
caution,  and  with  the  assent  of  the  surgeon.  I  have,  how- 
ever, in  more  than  one  instance  seen  it  apparently  save 
patients,  who  without  it  would  have  probably  died. 

(8)  In  post-operative  intestinal  paresis  (according  to 
Kemp,  gastrointestinal  paresis)  lavage  should  be  employed 
together  with  enteroclysis. 


INDICATIONS    FOR    GASTRIC    LAVAGE  1 87 

(9)  In  intestinal  obstruction,  especially  intussusception, 

frequent  lavage  sometimes  greatly  relieves  abdominal  dis- 
tention above  the  point  of  obstruction,  aiding  both  directly 
and  indirectly  its  spontaneous  reduction. 

(10)  Ice -water  lavage.  The  recommendation  that  lav- 
age of  ice  water  may  be  used  in  severe  hemorrhage  from 
ulcer  or  gastric  erosions,  is  put  forth  by  some  writers.  This 
does  not  meet  with  my  approval. 

(11)  Vomiting  in  peritonitis.  Some  recommend  it  for 
this,  but  only  at  the  direct  request  of  the  surgeon  in  charge 
should  it  be  employed.  While  it  might  be  of  doubtful 
benefit,  it  could  also  work  considerable  harm. 

Some  of  the  uncalled-for  and  misdirected  efforts  to  wash 
out  the  stomach  have  been  largely  responsible  for  the  preju- 
dices against  this  really  useful  therapeutic  procedure. 

The  contraindications  to  the  use  of  gastric  lavage  are  in 
the  main  the  same  as  those  against  the  use  of  the  tube  for 
the  aspiration  of  a  test-meal,  except  that  it  must  be  re- 
membered that  the  tube  must  remain  in  the  stomach  some- 
what longer  than  when  only  a  few  centimeters  of  fluid  con- 
tents are  to  be  extracted,  consequently  the  operator  must 
make  due  allowances  for  this  prolonged  time,  and  govern 
himself  accordingly. 

In  regard  to  the  tube  itself  this  was  practically  covered  in 
the  preceding  chapter.  It  might  be  permissible,  however, 
to  say  again  that  the  size  of  the  tube  should  run  from  1 8  to 
24  English — seldom  larger,  and  that  five  velvet-finished 
"eyes"  should  be  placed  at  near  intervals  on  opposite  sides 
and  near  the  end  of  the  tube.  There  should  be  no  opening 
in  the  end  of  the  tube. 

Most  tubes  are  marked  at  about  20  inches  from  the  distal 
end.  Should  they  not  be  marked,  it  is  well  for  the  operator 
to  make  a  circular  mark  at  this  distance  with  indelible  ink. 
It  is  ordinarily  about  1 6  to  18  inches  from  the  teeth  to  well 
within  the  stomach — the  distance  being  regulated  by  the 
stattu-e  of  the  individual  and  the  position  of  the  abdominal 
organs.     If  the  physician  will  insert  the  tube  i  to  3  inches 


I5«  GASTRIC   LAVAGE 

beyond  where  he  thinks  is  necessary,  he  will  then  have 
sufficient  slack  to  permit  of  a  gradual  retraction  of  the  tube, 
should  the  return  current  not  come  as  freely  as  it  should. 

The  same  general  directions  as  to  inserting  the  tube  are 
applicable  as  were  previously  described.  Some  operators 
insert  the  tube  into  a  bowl  of  cracked  ice  or  very  cold  water 
just  before  introducing.  Others  have  advocated  an  "in- 
troducer" or  guide,  as  devised  by  Dr.  M.  Knapp,  of  New 
York.  These  various  methods  I  have  found  to  be  time- 
consuming,  and  without  appreciable  value. 


Fig.  44. — Hemmetter's  double-current  stomach  lavage-tube. 


Many  forms  of  apparatus,  more  or  less  complicated,  have 
been  used  in  gastric  lavage,  some  of  them  being  so  involved 
that  the  slightest  untoward  incident  would  impair  the 
smooth  working  of  the  whole. 

I  shall  briefly  describe  some  of  those  in  regular  use,  and 
then  at  more  length  describe  the  method  I  have  found  most 
efficacious. 

Irrigation  of  the  stomach  by  means  of  a  glass  Y  or  T. 

This  has  generally  been  known  as  the  ' '  Leube-Rosenthal ' ' 
method  though  some  Americans,  among  them  being  Dr. 
R.  H.  M.  Dawbarn,  claim  to  have  used  it  fully  as  long  as 
the  Germans. 


METHODS    OF    GASTRIC   LAVAGE 


189 


A  large  glass  irrigator,  of  two  or  more  quarts  capacity,  is 
suspended  slightly  above  the  patient's  head.  This  irri- 
gator should  be  plainly  marked  in  cubic  centimeters  or 
ounces,  so  the  operator  can  know  just  how  much  he  is 
introducing  into  the  stomach.  This  irrigator  is  connected 
with  a  long  soft  rubber  tube  by  means  of  a  Y-  or  T-shaped 


Fig.  45. — ^Leube-Rosenthal  method  of  gastric  lavage.     (Bassler.) 

a,  Tube  leading  from  the  irrigator  jar  to  the  glass  Y;  b,  stomach-tube;  c,  drainage 

tube  leading  to  basin  on  floor. 

glass  connection;  one  branch  of  the  glass  connection  being 
inserted  into  a  stomach-tube,  the  other  into  a  carry-off 
tube  that  extends  into  a  pail  or  basin. 

Here  let  me  insert  an  earnest  word  of  caution.  Be  sure 
that  the  stomach-tube  is  safely  fitted  to  the  end  of  the  glass 
connector,  and  further  more,  that  the  end  of  this  stomach- 
tube  is  never  free  from  careful  observation.  Should  by  any 
reason  the  tube  become  disengaged,  and  accidentally  slip 


IQO  GASTRIC   LAVAGE 

down  the  esophagus  into  the  stomach  of  the  patient,  a 
serious  dilemma  is  at  hand.  This  tube  in  all  probability 
will  be  extricated  from  the  stomach  only  after  a  gas- 
trotomy,  and  in  addition,  if  the  patient  falls  under  bad 
influences,  the  physician  may  face  a  suit  for  damages. 
That  this  is  no  fanciful  picture,  the  records  of  our  courts 
will  verify.  Let  the  operator  always  be  sure  that  the  tube 
is  thoroughly  safe  and  under  his  control,  and  this  distress- 
ing accident  will  never  occur. 

The  irrigator  tube  should  be  closed  with  a  clamp,  which 
should  remain  in  place  until  the  stomach  tube  is  fully 
inserted.  A  second  clamp  is  needed  on  the  outflow  tube,  so 
that,  after  the  current  is  started,  it  can  be  regulated  by 
these  two  clamps. 

The  stomach-tube  being  in  place,  the  irrigator  tube  is 
opened,  while  the  outflow  tube  is  clamped.  This  continues 
until  about  lo  or  12  ounces  of  fluid  are  introduced  into  the 
stomach.  While  the  flow  is  still  entering  the  stomach,  the 
outflow  tube  is  suddenly  opened  and  a  part  of  the  current 
diverted,  thus  starting  the  siphon  action.  The  inflow  tube 
is  then  pinched,  allowing  the  outflow  tube  to  siphon  out 
the  stomach.  When  the  stomach  is  empty,  the  outflow 
tube  is  pinched,  the  inflow  is  opened,  and  the  same  process 
continued  until  the  lavage  is  complete. 

Some  operators  have  a  double,  or  even  a  triple  glass 
T-tube,  connecting  with  several  glass  containers,  in  which 
are  various  medicaments,  arranged  so  that  by  the  simple 
opening  of  a  clamp  the  stomach  may  be  laved  with  any  one 
of  them.  Some  of  these  contrivances  are  more  spectacular 
than  useful. 

Another  of  the  old  methods  is  the  Friedlieb  apparatus, 
consisting  of  a  rubber  funnel,  a  long  rubber  tube,  in  the 
middle  of  which  is  a  bulb,  with  or  without  valves.  The 
supposed  advantage  of  the  bulb  lies  in  the  ability  of  the 
operator  to  force  air  through  the  tube,  or  to  aspirate  air 
upward  in  it,  should  any  obstruction  occur. 

All  things  considered,  I  have  found  a  modiflcation  of  this 


GASTRIC    LAVAGE 


191 


Fig.  46. — First  step  in  gastric  lavage. 


GASTRIC   LAVAGE  1 93 

Friedlieb  apparatus  the  most  practicable  for  lavage  pur- 
poses. The  apparatus  I  prefer  consists  of  a  glass  funnel,  of 
lo  to  i6-ounce  capacity,  a  good,  resilient  red-rubber  tube 
about  24  English  size,  and  31/2  feet  long,  and  a  glass  con- 
nection, made  from  plain  glass  tubing,  with  the  ends 
rounded  by  the  flame  of  a  gas  or  Bunsen  burner.  This  glass 
tube  should  be  about  2  1/2  to  3  1/2  inches  long,  sufficiently 
large  to  allow  a  lumen  as  large  as  the  stomach-tube,  and 
the  space  between  its  fixation  in  the  tube  connected  with 
the  funnel.     Its  insertion  in  the  stomach-tube  should  be 


Fig.  47. — Lavage  apparatus. 

sufficiently  long  to  allow  the  operator  to  observe  the  direc- 
tion of  the  fluid  current,  its  gross  contents,  its  free  flow,  or 
its  obstruction. 

I  prefer  that  the  funnel  should  be  of  glass,  which  permits 
better  observation  of  the  movement  of  the  fluid  current. 
Care  should  be  taken  that  the  glass  outlet  tube  from  the  fun- 
nel be  ample  in  size.  Many  good  operators  prefer  a  hard 
rubber  funnel,  both  because  of  its  lightness  and  of  the  les- 
sened liability  to  breakage.  This  is  merely  a  matter  of 
preference. 

The  proper  lavage  tube  having  been  safely  affixed  to  the 
glass  connecting  tube,  it  is  introduced  into  the  esophagus,  as 
described  in  the  previous  chapter. 

It  is  occasionally  necessary  to  have  the  patient  a  little 
more  thoroughly  protected  than  when  a  test-meal  alone  is 
13 


194  GASTRIC   LAVAGE 

to  be  extracted,  but  I  seldom  find  it  needed,  the  two  towels 
being  ample. 

The  lavage  tube  being  in  the  stomach,  the  glass  funnel 
should  be  filled  with  plain  water,  held  up,  and  the  water 
allowed  to  flow  into  the  stomach.  Just  as  the  water  is 
disappearing  from  the  bottom  of  the  funnel,  the  funnel 
should  be  quickly  lowered,  so  as  to  get  the  siphon  action  of 
the  water.  Holding  this  funnel  down  just  clear  of  the  basin 
or  pail,  and  considerably  below  the  level  of  the  stomach,  the 
water  should  flow  back  promptly,  unless  obstructed  by 
lumps  of  undigested  food,  or  a  kink  in  the  tube.  If  the 
water  does  not  come  freely,  the  funnel  should  be  raised, 
about  6  ounces  of  water  poured  in,  and  the  effort  made 
again  to  get  a  return  flow.  If  necessary,  the  tube  may  be 
slightly  retracted,  or  moved  upward  and  downward  until 
its  end  is  engaged  in  the  fluid  in  the  stomach.  Be  sure  that 
the  tube  is  not  kinked  or  that  the  patient  is  not  involun- 
tarily biting  it.  In  the  great  majority  of  instances,  after 
one  to  three  attempts  the  water  flows  back  freely,  and  the 
lavage  can  be  kept  up  as  long  as  desired.  While  it  is  going 
on,  the  patient  should  sit  erectly,  the  head  thrown  a  little 
forward,  and  should  breathe  deeply  and  rhythmically. 
This  will  facilitate  the  treatment. 

Should  it  be  found  that  the  lavage  tube  is  tightly  clogged, 
so  that  the  return  siphonage  cannot  clear  it,  I  occasion- 
ally slip  out  the  connecting  glass  tube,  insert  my  Lockwood 
bulb,  and  with  two  or  three  quick  pressures,  with  my  finger 
closing  the  outlet,  I  drive  through  the  tube  enough  air  to 
clear  it.  During  this  procedure,  I  am  particular  never  to 
loose  my  hold  on  the  end  of  the  lavage  tube,  lest  it  escape 
and  be  swallowed.  Having  cleared  it,  I  replace  the  glass 
connecting  tube,  and  continue  as  before. 

Should  the  patient  find  the  ordeal  somewhat  trying,  as  is 
often  the  case  at  first,  it  might  be  well  for  the  operator  not 
to  attempt  a  thorough  lavage,  until  the  tube  is  better  toler- 
ated. Unwise  efforts,  colored  more  by  zeal  than  discre- 
tion, have  in  many  instances  prejudiced  patients  against 


GASTRIC   LAVAGE 


195 


Fig.  48. — Second  step  in  gastric  lavage. 


GASTRIC    LAVAGE 


197 


Fig.  49. — Third  step  in  gastric  lavage.     (Siphoning  out  the  lavage  liquid.) 


MEDICAMENTS    EMPLOYED   IN   LAVAGE  1 99 

this  procedure,  when,  if  the  operator  had  used  more  of  both 
time  and  patience  in  accustoming  the  irritable  epiglottis  and 
stomach  to  endure  the  tube,  results  would  have  been  more 
satisfactory  to  all  concerned. 

I  have  in  many  instances  at  the  first  attempt,  siphoned 
out  only  one  or  two  funnels  of  fluid,  so  as  to  permit  the 
patient  to  discover  that  gastric  lavage  was  not  so  horrible  as 
pictured.  After  the  patient's  mental  attitude  has  become 
favorable,  the  lavage  can  then  be  made  just  as  thorough  as 
desired. 

The  temperature  of  the  lavage  fluid  should  be  in  the  neigh- 
borhood of  100  to  105°  F.  Cold  water  is  nearly  always 
disagreeable  to  the  patient,  and  very  hot  water,  apart  from 
the  danger  of  burns,  makes  the  patient  uncomfortably 
warm — sometimes  bringing  on  faintness. 

There  are  quite  a  number  of  medicaments  used  in  the 
lavage  water,  and  I  shall  briefly  mention  some  of  them  that 
are  the  most  useful  and  rational.  It  would  be  impossible  to 
name  all  that  have  been  recommended,  for  some  have  been 
as  freakish  as  the  charms  and  philtres  of  the  middle  ages. 

The  medicament  to  be  employed  is  of  course  governed 
by  the  gastric  condition,  whether  there  be  irritation  of  the 
mucosa,  atony,  stagnation  of  the  contents,  fermentation, 
hyperacidity  or  hypoacidity,  or  abnormal  states  brought 
about  by  anatomic  lesions,  malignant  or  otherwise. 

It  is  well  to  always  use  plain  water  until  the  return  flow  is 
established,  and  continue  until  the  stomach  is  fairly  clean. 
The  medicated  solution  may  then  be  used,  followed  by  the 
plain  water.  Occasionally  some  medicated  solution  is 
left  in  the  stomach  at  the  close  of  the  lavage. 

Among  the  agents  used  are  boric  acid,  simple  salt,  bicar- 
bonate of  soda,  nitrate  of  silver,  ichthyol,  permanganate 
of  potash,  peroxide  of  hydrogen,  carbolic  acid,  subnitrate 
of  bismuth,  calcined  magnesia,  etc.  Another  preparation 
possessing  a  wide  range  of  usefulness  is  the  alkaline  antisep- 
tic liquid  (National  Formulary)  which  is  inexpensive,  and 
adaptable  to  nearly  all  fermentative  states. 


200  GASTRIC   LAVAGE 

The  operator  shoiild  have  on  a  table,  convenient  to  his 
hand,  a  pitcher  containing  from  1/2  to  i  gallon  of  warm 
water,  A  larger  pitcher  is  too  bulky  and  hard  to  manipu- 
late. He  should  also  have  a  pint  receptacle  in  which  is  his 
medicated  fluid.  There  can  be  on  the  table  calcined  mag- 
nesia, bismuth,  soda,  or  any  other  powder,  which  may  be 
indicated.  All  these  'should  be  ready  for  when  he  starts 
the  lavage  he  shoiild  be  prepared  to  go  through  with  it 
expeditiously.  To  stop  right  in  the  midst  of  a  lavage  to 
look  for  something  or  to  complete  some  unfinished  prepara- 
tion, is  vexatious  both  to  the  physician  and  patient. 

Should  there  be  an  irritable  condition  of  the  gastric 
mucosa,  calling  for  nitrate  of  silver,  the  pint  receptacle 
may  be  filled  with  a  i  to  500  solution,  which  may  be 
employed  midway  of  the  lavage.  Should  there  be  a  fer- 
mentative or  stagnated  condition  of  the  stomach,  requiring 
efficient  cleansing,  either  ichthyol,  to  a  mahogany  color, 
permanganate  of  potash,  i  to  1000,  or  alkaline  antiseptic 
liquid  may  be  employed  in  the  medicated  solution. 

Should  there  be  an  extremely  acid  state  of  the  stomach, 
there  can  be  used  in  the  larger  pitcher,  either  common  salt, 
soda,  or  calcined  magnesia.  The  last  named,  will  not  dis- 
solve, but  can  be  kept  in  suspension  by  agitation,  and  is 
most  useful. 

After  the  medicated  fiuid,  plain  water  should  follow,  and 
the  lavage  should  be  kept  up  till  the  water  returns  clear, 
unless  there  is  a  good  reason  for  stopping. 

At  the  close  of  the  lavage,  it  is  often  advisable  to  leave 
some  agent  in  the  stomach.  In  acid  conditions,  with  con- 
stipation, I  frequently  leave  a  funnel  of  water  in  which 
is  placed  one  or  more  heaping  teaspoonfuls  of  calcined 
magnesia.  This  not  only  neutralizes  the  present  hyper- 
acidity, but  also  exerts  a  pleasant  hydragogue  effect  in  a 
short  while.  Should  there  be  erosions  of  the  gastric 
mucosa,  I  often  leave  in  the  stomach  a  liberal  teaspoonful 
of  bismuth  mixed  in  half  a  funnel  of  water. 

The  best  time  of  day  for  gastric  lavage  is  governed  by 


TIME   AND   FREQUENCY   OF   LAVAGE  20I 

circumstances.  Unless  it  is  to  rid  the  stomach  of  undesir- 
able contents,  the  lavage  is  best  performed  on  an  empty 
stomach,  preferably  in  the  morning  before  breakfast.  In 
atonic  conditions  of  the  viscus,  the  lavage  should  be  per- 
formed the  last  thing  before  the  patient  retires,  if  possible, 
as  both  the  cleansing  and  rest  do  their  respective  parts. 
Dr.  J.  W.  Weinstein,  of  New  York,  is  quite  insistent  as  to 
this  detail,  claiming  excellent  results  thereby. 

So  far  as  practicable,  the  time  should  be  arranged  so  that 
the  patient  will  not  lose  the  large  part  of  a  meal  by  lavage. 
Most  of  these  patients  are  illy  nourished,  and  the  loss  of  a 
liberal  part  of  a  meal  every  one  or  two  days  constitutes 
quite  a  caloric  item. 

Should  it  not  be  convenient  to  irrigate  the  stomach 
before  the  morning  meal,  I  generally  try  to  have  such 
patients  come  in  about  noon  or  a  little  later,  as  an  eight 
o'clock  breakfast  will  have  been  fairly  well  disposed  of  by 
that  time.  It  is  much  easier  for  both  the  subject  and 
physician  to  have  the  stomach  as  empty  as  possible,  for 
the  washing  out  of  great  masses  of  undigested  aliment 
before  the  purposeful  lavage  begins,  is  provoking  and  time- 
consuming. 

The  frequency  with  which  lavage  can  be  profitably  and 
harmlessly  repeated  is  another  mooted  question.  I  know 
of  one  busy  gastroenterologist  who  is  reputed  to  often  wash 
out  the  same  stomach  daily  for  several  months.  From 
this  I  dissent.  Unless  there  is  a  decided  interference  with 
the  proper  emptying  of  the  stomach,  whereby  there  is  a 
fermenting  residue  present,  a  daily  lavage  is  seldom  wise. 
Many  of  these  cases  really  do  better  with  lavage  on  alter- 
nate days.  In  the  presence  of  a  hyper-sensitive  gastric 
mucosa,  lavage  should  be  performed  with  caution  and  not 
too  often.  An  occasional  application  of  nitrate  of  silver 
to  the  hyper-sensitive  surface  is  beneficial,  when  not  too 
often  applied.  Constant  and  persistent  lavage  in  such 
cases  generally  works  more  harm  than  good. 

In   chronic   gastritis,    with   excessive   mucus,    a   lavage 


202  GASTRIC   LAVAGE 

two  to  three  times  weekly  is  generally  of  aid.  Daily  lavage 
tends  to  produce  irritation. 

The  "lavage  habit"  into  which  some  patients  (occasion- 
ally physicians)  lapse,  is  a  most  unfortunate  one.  These 
individuals,  having  learned  to  use  the  tube  themselves,  and 
finding  that  the  emptying  of  an  overdistended  stomach 
will  bring  about  relief  from  epigastric  distress,  make  it  a 
practice  to  hasten  for  the  tube,  and  wash  out  the  stomach 
with  the  first  qualm.  Some  of  these  misguided  sufferers 
wash  out  their  stomachs  from  two  to  four  times  daily, 
bringing  their  bodies  to  the  verge  of  caloric  bankruptcy  by 
their  unwise  zeal.  It  is  allowable  under  certain  circum- 
stances to  teach  the  patients  how  to  administer  to  them- 
selves a  gastric  lavage,  as  when  they  live  in  isolated  locali- 
ties, or  when  it  is  impracticable  to  see  the  physician  at  the 
proper  time.  Such  instruction,  however,  should  be  given 
only  for  good  and  sufficient  reasons,  and  the  patient  should 
be  admonished  of  the  dangers  that  lie  in  wait  for  those  who 
fly  to  the  stomach-tube  not  wisely  but  too  often. 

If,  therefore,  gastric  lavage  is  employed  for  a  definite 
purpose,  under  proper  restrictions,  in  a  deft  manner,  and 
not  as  a  routine  measure,  it  may  be  productive  of  great 
benefit;  otherwise  it  is  liable  to  cause  harm,  and  to  bring 
it,  as  a  therapeutic  method,  into  disrepute. 


CHAPTER  VIII 

VARIOUS   METHODS   OF   LOCAL   TREATMENT   OF 
THE  STOMACH,  INTERNAL  AND  EXTERNAL 

Many  have  been  the  methods  devised  for  local  treatment 
of  the  stomach  and  abdomen,  some  rational  and  logical; 
some  irrational,  illogical,  and  even  bizarre.  That  some  of 
these  latter  have  apparent  cures  to  their  credit  may  be  to  a 
large  extent  attributed  to  psychic  influence,  or  to  novel 
sensations  that  would  give  the  patient's  mind  some  change 
from  his  constant  introspection. 

The  Stomach  Douche. — This  should  be  employed  only 
when  the  stomach  is  empty,  the  object  being  to  lave  the 
gastric  mucosa  with  plain  water  or  a  medicated  solution. 
The  tube  for  this  should  have  at  its  end  many  small  open- 
ings, mostly  lateral,  and  the  fluid  should  flow  into  the  stom- 
ach with  considerable  force. 

To  properly  douche  the  viscus,  the  tube  should  be  first 
introduced  only  about  17  or  18  inches,  and  the  douche 
applied.  When  the  stomach  has  taken  12  or  16  ounces, 
the  tube  should  be  slipped  down  3  or  4  inches,  and  the  con- 
tents siphoned  out.  The  tube  should  then  be  retracted, 
and  the  douche  applied  as  before.  It  will  be  readily  seen 
that  no  douche  can  elEfectively  reach  the  stomach  walls 
while  the  organ  is  full  of  fluid. 

Turck  has  devised  a  double-flow  stomach  douche,  con- 
sisting of  two  rather  small  tubes  cemented  together;  one 
being  longer  than  the  other,  serves  to  siphon  out  the  fluid, 
while  the  short  one,  with  many  ^mall  openings,  allows  the 
fluid  to  strike  the  stomach  walls  in  numerous  small  jets. 

The  Gastric  Spray. — This  consists  of  an  ordinary  spray- 
ing apparatus,  to  which  is  connected  a  soft  stomach-tube, 
containing  a  fine  flexible  tube.     This  smaller  tube  has  on 

203 


204  VARIOUS  METHODS  OF  TREATMENT  OE  THE  STOMACH 

its  end  a  nozzle,  through  which  the  fluid  may  be  sprayed 
into  the  stomach  as  do  the  laryngologists.  Einhorn,  who 
devised  this  method,  recommends  it  highly,  as  but  a  small 
amount  of  fluid  is  required,  and  no  toxic  manifestations 
are  liable  when  rather  strong  solutions  are  used. 

The  spray  is  best  employed  after  a  previous  lavage. 
The  bottle  is  filled  with  the  required  solution,  the  tube 
dipped  in  water,  and  introduced  in  the  usual  manner.  The 
spraying  should  be  begun  when  the  tube  has  entered  from 
1 6  to  1 8  inches,  and  during  its  continuance  the  tube  should 
be  gently  put  in  further  and  retracted  several  times  so  as 
to  more  thoroughly  reach  the  whole  gastric  surface.  It 
appears  that  the  insufflation  of  air  along  with  the  fine  spray 
distends  the  stomach,  permitting  the  medicated  fluid  to 
reach  all  of  the  rugosities.  This  spray  is  useful  to  disinfect 
the  mucous  membrane,  for  which  gentle  antiseptics  may 
be  employed.  It  is  also  recommended  in  simple  erosions 
of  the  stomach,  in  chronic  gastritis,  with  excess  production 
of  mucus,  in  hypersecretion  and  hyperacidity  with  gastral- 
gia.  It  seems  especially  efficacious  in  the  treatment  of 
gastralgia,  with  or  without  erosions. 

Stomach  Powder -blower. — This  apparatus  for  spraying 
the  stomach  with  insoluble  substances  in  powder  form  was 
first  devised  by  Einhorn.  His  instrument  consists  of  a 
flexible  rubber  tube  about  28  inches  long,  the  distal  end  of 
which  connects  with  an  air  suction  bulb.  The  extremity 
of  the  tube  is  attached  to  a  hard-rubber  piece,  which  is 
hollow  and  has  quite  a  number  of  lateral  openings.  This  is 
provided  with  a  screw  thread.  To  this  is  attached  a  cap- 
sule with  many  side  holes,  capsules  of  several  sizes  being 
furnished.  A  capsule  is  filled  with  powder  and  screwed  on 
to  the  tip  piece.  It  is  well  to  lubricate  the  latter  with  vase- 
line to  prevent  too  early  entrance  of  moisture.  The  tube 
is  dropped  into  water  and  inserted  in  the  usual  way.  The 
bulb  is  then  quickly  compressed  several  times,  and  the  air 
drives  out  the  powder,  after  first  loosening  up  the  thin  layer 
of  vaseline. 


ELECTRICITY  205 

During  the  spraying  the  tube  may  be  gently  moved 
upward  and  downward,  as  previously  suggested. 

This  device  may  be  appropriately  employed  in  several 
conditions,  with  various  powders;  in  ulcer  of  the  stomach, 
employing  bismuth  subnitrate  or  subgallate;  in  gastralgia, 
orthoform  or  chloretone;  and  in  erosions,  using  protargol, 
suprarenal  powder  or  tannigen. 

Its  use  for  ulcer  would  call  for  very  careful  manipulation, 
and' not  too  soon  after  any  hemorrhage. 

ELECTRICITY 

Clinical  observation  and  experience  have  demonstrated 
that  electricity  in  various  forms  exercises  an  actual  and 
tangible  effect  upon  the  secretory  and  motor  functions  of  the 
stomach,  and  also,  to  a  certain  extent,  on  its  sensibility.  As 
Kemp  wisely  remarks,  however,  physiologic  experiments 
and  clinical  experience  do  not  always  agree. 

At  the  present  time  there  is  much  controversy  concerning 
the  real  effect  of  electricity  intragastrically  employed,  some 
physiologists  decrying  its  value,  while  competent  clinicians 
are  reporting  marked  benefit  in  numerous  cases.  Even 
among  stomach  workers  there  is  diversity  of  opinion. 
Einhorn  believes  that  the  faradic  current  promotes  secre- 
tion, and  the  galvanic  impedes  it;  Hoffman,  that  the  gal- 
vanic current  increases  secretion,  and  Brocci  that  the  far- 
adic augments  both  secretion  and  peristalsis.  Bassler 
believes  that  the  effects  of  the  galvanic  current  are  of  a 
sedative  nature  in  the  relief  and  control  of  abnormal  dis- 
turbances of  gastric  sensation,  and  that  it  has  a  mild  inhib- 
iting effect  upon  some  stomachs  on  the  hydrochloric  acid 
secretion,  but  not  as  often  on  the  quantity  of  enzymes;  and 
that  the  faradic  current  is  of  value  in  the  myasthenic  states 
of  the  muscular  tissue  of  the  stomach,  provided  the  pylorus 
is  patent,  and  also  if  the  deficient  musculature  has  not  gone 
on  to  paralytic  atony.  Added  to  this  is  an  effect  (probably 
complex  in  its  nature)  on  the  abdominal  sympathetic  sys- 


206    VARIOUS   METHODS    OF   TREATMENT   OF   THE    STOMACH 

tern,  in  which  the  nutrition  of  the  stomach  wall  as  a  whole  is 
improved.  Whether  this  is  due  to  the  massaging  of  the 
stomach  walls  by  the  contracture  of  the  muscle  fibers  from 
the  current,  or  is  due  to  some  direct  action  of  the  current  on 
the  nerve  endings  and  centers  in  the  posterior  abdomen, 
Bassler  does  not  attempt  to  say.  Furthermore  it  has  a 
somewhat  mysterious,  but  none  the  less  beneficial  effect  in 
perhaps  a  suggestive  manner  upon  many  individuals,  suffer- 
ing from  gastric  troubles  of  possibly  a  neurotic  character. 
Because  we  cannot  fully  explain  its  action,  is  no  reason  why 
we  should  not  avail  ourselves  of  its  aid. 

Bassler  reports  two  most  instructive  cases,  studied  by 
him  per  X-ray,  in  which  he  proved  that  the  faradic  current 
increases  peristalsis,  and  causes  the  entire  stomach  to 
become  smaller  in  size.  One  was  a  case  of  gastroptosis  in  a 
young  woman,  and  the  other  a  simple  atony  following  the 
taking  of  too  large  quantities  of  fluids  in  a  young  man,  who 
worked  as  a  coal  stoker  in  an  engine  room.  His  observa- 
tions were  conducted  with  bismuth  subnitrate  and  water  in 
an  otherwise  empty  stomach,  when  he  noted  distinctly  a 
mild  running  peristalsis  in  the  lower  half  of  the  stomach  in 
both  instances.  After  the  electrode  was  introduced,  and 
before  the  faradic  current  was  turned  on,  the  peristalsis  was 
somewhat  more  marked;  possibly  due  to  presence  of  the 
cord  and  end  piece  within  the  organ.  When,  however,  the 
faradic  current  was  delivered  to  the  tolerance  of  the  person 
(external  electrode  at  the  sides  of  the  neck)  and  evident  con- 
traction of  the  entire  organ  took  place,  it  was  followed  by  a 
less  degree  of  relaxation  and  increased  peristalsis. 

Speaking  somewhat  generally,  I  might  say  that  the  best 
results  are  obtained  in  atonic  stomachs  with  sluggish  motor 
power,  by  the  use  of  the  faradic  current,  with  the  positive 
end  of  the  current  discharged  within  the  stomach,  and  the 
external  electrode  (negative)  on  the  back  or  preferably  on 
the  epigastrium. 

In  regard  to  the  power  of  the  current  no  inflexible  rule 
can  be  laid  down.     It  should  be  given  to  the  comfortable 


ELECTRICITY  207 

tolerance  of  the  patient,  and  not  pushed  to  discomfort. 
Nearly  every  patient  will  display  a  difference  in  tolerance, 
and  each  one  must  be  a  rule  unto  himself.  From  5  to  20 
milliamperes  is  an  average  requirement. 

Numerous  intragastric  electrodes  have  been  devised,  of 
which  the  most  practical  are  Bassler's,  Lockwood's  and 
Einhorn's. 

Bassler's  seems  to  possess  some  advantage  in  the  '  'intro- 
ducer," which  is  withdrawn  after  the  bulb  enters  the  stom- 
ach. Some  patients  find  it  rather  difficult  to  swallow  the 
rubber,  fenestrated  capsule. 

The  electric  treatments  should  last  from  eight  to  twelve 
minutes,  though  the  faradic  can  with  propriety  last  some- 


FiG.  50. — Einhorn's  divisible  esophageal  bougie. 

what  longer  than  the  galvanic.  The  patient  should  always 
have  one  or  more  glasses  of  water  in  the  stomach.  The 
external  electrode  may  be  gently  moved  about,  and  the 
current  may  be  gradually  increased  from  time  to  time. 
Should  the  patient  become  nervous  or  ill  at  ease,  the  treat- 
ment should  be  cut  short,  for  it  can  do  no  good  under  such 
circumstances,  and  might  do  harm.  Care  should  be  taken 
that  the  current  is  not  painful,  and  the  operator  should 
remember  that  the  wetter  the  sponge,  the  greater  is  the 
intensity  of  the  current. 

When  it  seems  desirable  to  permit  the  current  to  flow 
to  a  large  external  area  (the  back)  the  large  external  elec- 
trode may  be  used  in  place  of  the  hand  instrument.  In 
cases  of  vague  pains  in  the  back,  associated  with  loaded 


208    VARIOUS   METHODS   OF   TREATMENT   OF   THE   STOMACH 

colon,  autointoxication,  gastric  neuroses,  etc.,  it  is  of  much 
value  to  place  the  large  electrode  over  the  area  correspond- 
ing to  the  great  sympathetic  plexuses  in  the  upper  abdomen. 

As  to  frequency  of  treatments,  I  usually  administer 
intragastric  electricity  every  second  day  for  one  to  two 
weeks ;  then  two  or  three  times  weekly  for  two  more  weeks ; 
then  once  a  week  for  as  long  a  time  as  may  be  indicated. 
This  schedule  is  modified  at  all  times  by  the  patient's 
temperament,  convenience,  sometimes  inclination,  and  by 
the  results  apparently  attained. 

Percutaneous  Electricity. — Some  patients  do  not  seem 
able  or  willing  to  undergo  intragastric  electricity,  and  with 
these  it  is  sometimes  advisable  to  administer  it  entirely 
from  without,  with  the  idea  that  the  current  employed  will 
course  directly  through  the  body  and  therefore  through  the 
desired  viscera.  There  is  probably  no  branch  of  thera- 
peutics in  which  we  get  more  contradictory  reports  than 
concerning  electricity,  and  many  of  these  reports  are  colored 
with  an  optimism  that  would  make  the  late  Sinbad  the 
Sailor  open  his  eyes  in  surprise;  while  others,  with  just  as 
much  pessimism,  find  absolutely  no  benefit  from  any  kind 
of  electricity. 

Having  had  occasion  to  use  electricity  quite  often  in 
gastrointestinal  work,  and  with  apparent  benefit,  I  have 
come  to  certain  conclusions,  which  I  will  briefly  state. 

By  the  use  of  a  fairly  large  epigastric  electrode,  which  is 
placed  over  the  stomach  or  lower  down  over  the  abdomen, 
and  a  smaller  electrode,  placed  on  the  spinal  column 
directly  opposite,  a  current  will  be  sent  through  the  organs 
desired.  This  current  may  be  regulated  according  to  the 
sensibility  and  comfort  of  the  patient,  making  it  distinctly 
perceptible,  but  never  uncomfortable.  The  patient  should 
generally  lie  on  the  side  in  an  easy  position,  and  can  assist 
the  operator  by  holding  one  of  the  two  electrodes.  The 
treatment  may  last  from  six  to  twelve  minutes. 

Apart  from  the  general  rule  that  the  currents  will  connect 
through  the  shortest  distance,  we  cannot  be  sure  as  to  the 


ELECTRICITY  209 

special  conductivity  of  any  particular  organ,  and  we  there- 
fore have  to  rely  on  a  certain  amount  of  diffusion  of  the 
electricity  as  it  courses  through  the  body. 

I  have  principally  employed  this  form  of  electricity  in 
the  various  so-called  gastric  neuroses,  gastroptosis  and 
enteroptosis,  dilated  and  atonic  stomachs,  flabby  and  in- 
competent abdominal  parietes,  chronic  colitis,  mucous 
colitis,  gastralgias,  nervous  anorexia,  and  the  many  vague 
epigastric  and  abdominal  discomforts,  in  which  the  patient 
cannot  give  a  succinct  description  of  his  troubles,  but 
constantly  and  bitterly  complains. 

In  many  of  these  patients  the  electricity  is  employed 
somewhat  empirically,  but  none  the  less  successfully. 
Just  how  much  of  the  improvement  is  brought  about  by 
psycliic  means  I  am  unable  to  say.  Probably  much  of  the 
benefit  should  be  attributed  to  the  novel  sensations  which 
start  a  favorable  "wave  of  improvement"  deep  down  in 
the  sub-conscious  personality,  which  in  turn  exerts  a 
beneficent  influence  on  the  sensory  centers.  This  I  admit 
is  to  a  great  extent  speculative,  and  I  simply  state  that  in 
many  chronic  cases,  where  various  forms  of  rational  and 
logical  treatment  have  been  without  avail,  electro-therapy 
has  wrought  most  satisfactory  results. 

Its  use  should  not  be  condemned  because  we  do  not 
thoroughly  comprehend  its  action,  but  from  its  many 
apparent  good  restilts,  we  are  justified  in  availing  ourselves 
of  its  possible  advantages. 

Static  Electricity. — This  has  been  recommended  in  much 
the  same  types  as  call  for  faradic  or  galvanic  electricity. 
It  has  been  found  useful  in  flabby  and  dilated  stomachs, 
and  in  gastric  and  intestinal  neuroses.  Especially  favorable 
has  been  the  effect  of  static  electricity  in  the  run-down 
class  of  "nervous  dyspeptics,"  whose  minds  continually 
dwell  on  their  digestive  organs,  and  whose  waking  thoughts 
are  entirely  introspective.  In  these  cases  the  static  current 
administered  rather  energetically  for  ten  or  fifteen  minutes 
daily  seems  to  act  quite  favorably,  exciting  a  new  train  of 
14 


2IO  VARIOUS  METHODS  OP  TREATMENT  OF  THE  STOMACH 

sensations,  and  steadying  the  somewhat  unstable  nerves. 
In  cases  of  nervous  indigestion,  wherever  practicable,  I 
always  avail  myself  of  the  static  current.  Unfortunately, 
this  procedure  is  available  in  only  a  limited  number 
of  cases. 

Before  passing  on,  I  wish  to  very  briefly  mention  electrical 
treatment  in  esophageal  diseases.  For  esophagismus  or 
cardiospasm  electricity  is  often  indicated,  and  will  in  some 
instances  afford  brilliant  results.  Other  disorders  of  the 
esophagus,  when  reflex  or  apparently  neurotic  in  origin  are 
amenable  to  this  agent.  I  wish  to  caution  my  readers, 
however,  as  to  expecting  any  material  improvement  from 
electricity  in  cicatricial  stenoses  of  the  esophagus  with 
malignant  tendencies.  The  dissolving  of  cicatricial  tissues 
or  the  relief  of  stenosis  by  electrolysis  has  not  proven  effec- 
tive, and  instead  has  changed  ill-advised  hope  into  black 
disappointment  many  times.  It  would  be  most  unwise  on 
the  part  of  the  internist  to  hold  out  to  a  patient  with  a 
stenosed  esophagus  any  strong  promises  of  either  ultimate 
or  lasting  improvement  by  electricity  in  any  form. 

X-ray  Therapy. — Some  years  ago  several  observers 
reported  flattering  results  from  X-ray  treatment  of  malig- 
nant stomach  affections.  Further  investigation  of  this 
agency  has  not  proved  its  merits,  and  it  is  now  seldom 
depended  on  in  such  conditions.  I  may  say  that  it  is  now 
the  general  opinion  among  conservative  students  that 
the  X-ray  is  absolutely  of  no  value  in  the  cure  of  gastric 
carcinoma,  sarcoma,  and  even  those  slower  types  of 
malignant  disease  following  chronic  ulcer.  In  some  of  the 
late  cases  of  carcinoma,  liberal  use  of  the  rays  may,  for  the 
time  being,  apparently  stay  the  onward  progress  of  the 
growth,  but  in  reality  the  benefits  are  derived  mainly 
from  suggestion.  Some  patients  aver  that  pain  is  amelior- 
ated by  the  rays,  but  the  anodyne  effect  falls  far  short  of 
morphine.  It  may  be  worth  while  to  employ  these  rays  in 
far-advanced,  inoperable  cases,  where  the  patient  demands 
that  some  form  of  therapeutic  procedure  be  persistently 


X-RAY    AND    RADIUM    THERAPY  211 

followed,  but  no  sanguine  hopes  should  be  built  upon  such 
desperate  means.  As  to  its  use  in  early  malignant  disease, 
it  cannot  be  too  strongly  deprecated.  By  depending  upon 
such  fallacious  methods,  valuable  time  may  be  wasted, 
time  which  may  spell  to  the  patient  the  difference  between 
life  and  death. 

As  an  auxiliary  to  the  medical  treatment  of  acute  gastric 
and  duodenal  ulcers,  after  these  patients  have  left  their 
beds,  the  X-rays  have  a  probable  useful  field.  Dr.  Bassler 
uses  this  means  quite  frequently,  and  seems  to  feel  that  he 
has  achieved  positive  good  results.  He  says — "  I  am  quite 
sure  that  the  number  of  cases  of  half -healed  ulcers,  spasmed 
and  irritative  states  of  the  stomach  are  fewer  with  me  to-day 
than  they  were  several  years  ago,  and  this  I  do  not  attribute 
particularly  to  any  improvement  in  plan  of  any  medical 
treatments  I  now  employ.  I  am  inclined  to  believe  that  the 
rays  stimulate  the  mucosa  to  a  better  repair  of  the  ulcer,  and 
that  the  resulting  scar  is  not  so  stiff.  The  rays  should  be 
used  in  these  cases  as  one  of  the  last  meastires  of  routine  treat- 
ment, after  the  bed,  dietetic,  and  medicinal  care  for  the  acute 
stage  of  the  ulcer  are  concluded." 

Radium  Therapy. — This  agent  was  first  used  by  Einhorn 
in  1904,  and  for  a  time  promised  flattering  results.  He 
first  employed  for  the  stomach  a  hard-rubber  capsule  that 
could  be  unscrewed,  and  which  contained  a  glass  radium 
flask  (Curie  20,000  strength).  To  the  rubber  capsule  he 
attached  a  silk  thread,  in  which  several  knots  were  tied 
indicating  the  distance  from  the  lips  to  the  cardia  and  how 
far  the  capsule  lay  from  the  cardia.  The  capsule  was  intro- 
duced in  a  similar  manner  to  the  stomach  bucket.  When 
the  capsule  has  descended  as  far  into  the  esophagus  or 
stomach  as  desired  by  the  operator,  the  thread  is  tied  to  the 
lobe  of  the  ear,  and  the  capsule  left  in  the  stomach  an  hour 
or  more.  Dr.  Einhorn  has  not  as  yet  formed  definite  con- 
clusions as  to  the  tangible  benefits  from  radium,  though  he 
thinks  he  has  observed  some  palliative  effects  in  a  few  cases. 
Kemp  reports  serious  burns  from  prolonged  exposure,  and 


212  VARIOUS  METHODS  OF  TREATMENT  OF  THE  STOMACH 

therefore  does  not  consider  the  likelihood  of  improvement 
commensurate  with  the  possible  dangers  incurred.  Bassler 
reports  the  assiduous  treatment  with  radium  of  seven  cases 
of  gastric  and  four  cases  of  esophageal  carcinoma,  and  con- 
fesses to  a  general  failure  in  all  of  them.  Other  writers 
express  the  rather  unanimous  sentiment  that  radium  as  a 
therapeutic  agent  in  gastrointestinal  diseases  is  of  no  real 
service. 

Vibration. — This  method  of  treatment  has  been  ex- 
tremely popular,  and  many  forms  of  vibrators  have  been 
devised,  some  of  them  quite  expensive.  They  have  varied 
from  the  simple  hand-vibrators,  costing  but  little  up  to  the 
elaborate  and  expensive  contrivances.  Many  of  the 
patented  machines  which  have  been  extensively  advertised, 
and  foisted  upon  the  public  as  wonderful  discoveries,  were 
in  reality  only  vibrators  masking  under  high-sounding 
names.  It  must  be  admitted  that  vibration,  when  properly 
applied,  does  exert  a  beneficial  effect  upon  certian  disorders 
of  the  alimentary  tract,  and  the  subject  will  be  briefly 
discussed. 

There  are  several  hand  vibrators  on  the  market  (The 
Vedee  and  the  Eureka)  which  can  be  used  where  electricity 
is  not  available.  There  are  many  others  that  can  be 
attached  to  the  street  current  in  the  patient's  residence  or 
in  the  physician's  office. 

There  are  other  small  hand  vibrators  now  manufactured 
and  also  small  vibrators  which  can  be  run  by  a  portable 
storage  battery,  thus  making  them  available  to  all. 

Vibratory  massage  should  be  given  from  left  to  right 
over  the  stomach  for  three  to  five  minutes,  then  two  to 
three  minutes  to  the  left  of  the  seventh  dorsal  vertebra, 
and  then  about  two  minutes  more  over  the  stomach. 

When  vibrating  over  the  colon,  the  general  course  of 
the  large  intestine  should  be  followed,  giving  most  of  the 
vibration  over  the  sigmoid.  In  the  early  morning  hours, 
or  before  breakfast  is  the  best  time  to  vibrate  the  intestines, 
while  later  in  the  day,  after  nourishment  has  been  taken,  is 


VIBRATION 


213 


the  better  time  for  thus  stimulating  the  stomach  and  nearby 
viscera. 

Bassler  has  recently  devised  an  electro  vibrator,  which 
seems  to  combine  the  benefits  of  mechanical  vibration 
and  electricity.  He  has  employed  this  method  in  disturbed 
states  of  motility,  sensory  and  secretory  conditions  of  the 
stomach,  and  claims  better  results  than  with  the  single 
forms  of  physical  treatments.  The  best  results  in  his 
opinion  were  attained  in  those  cases  in  which  the  gastric 
disturbance  was  secondary  to  enteric  disturbance.  Bassler 
sums  up  his  experience  in  a  broad  way,  and  I  quote  him  at 
some  length,  as  his  views  express  in  a  fairly  complete  man- 
ner the  indications  and  contraindications  for  electro- 
vibration  : 

"Electrovibratory  massage  is  of  value  in  the  therapy  of 
abdominal  conditions  in  all  motor,  some  sensory  and  a  few 
secretory  disturbances  of  the  intestines,  both  locally  and  as 
they  may  directly  or  reflexly  affect  the  stomach  or  other 
parts  of  the  body;  that  it  is  a  measure  of  value  in  the  dis- 
turbed states  of  local  nutrition  of  the  reachable  abdominal 
organs,  and  in  the  abdomen  as  a  whole — its  influence  here 
is  to  better  the  general  state  of  health,  and  favorably 
influence  those  catabolic  and  neurasthenic  conditions  which 
take  their  origin  in  the  abdominal  cavity;  that  it  is  the 
best  single  medical  measure  we  have  to-day  in  the  treat- 
ment of  exudates  and  fibrous  adhesions  found  about  the 
abdominal  portions  of  the  alimentary  canal;  that  in  those 
mysterious  tardy  forms  of  intestinal  indigestion,  and  also 
in  the  long-standing  catarrhal  conditions,  it  might  be  em- 
ployed with  satisfactory  benefit  to  a  patient ;  that  it  is  the 
best  form  of  percutaneously  applied  physical  treatment  we 
have  for  abdominal  conditions,  ahead  of  hand  massage, 
vibration,  or  the  externally  applied  battery  current;  that 
its  use  should  always  be  preceded  by  an  accurate  diagnosis, 
since  in  some  of  the  conditions  of  the  gastroenteric  tract 
it  might  do  positive  harm  (malignant  disease,  ulcers  of  any 
type,  acute  catarrhal  and  suppurative  states) ;  that  follow- 


214    VARIOUS   METHODS    OF   TREATMENT   OF   THE    STOMACH 

ing  a  plausible  indication  for  its  use,  it  should  be  employed 
by  the  physician  himself,  or  under  his  immediate  direction, 
in  suitable  combination  for  the  case  in  the  way  of  the  plan 
of  massage  and  selection  of  the  current;  and  that,  lastly, 
it  should  be  employed  with  a  consistent  and,  if  needs  be, 
long-kept-up  effort  to  accomplish  these  ends." 

In  applying  vibration  the  patients  should  lie  at  ease  on 
a  long  table  and  the  skin  should  be  dusted  with  some  pre- 
pared chalk  or  talcum  powder,  so  that  the  instrument  will 
move  easily  on  the  surface.  The  patient  should  relax  the 
abdominal  walls  as  much  as  possible,  and  should  assume  a 
comfortable  position,  so  that  none  of  the  muscles  are  taut. 
The  treatment  may  last  from  three  to  ten  minutes,  regulat- 
ing both  the  rate  of  vibration,  the  strength  of  current,  and 
the  force  of  pressure  according  to  the  susceptibility  of  the 
patient. 

I  have  used  this  method  in  quite  a  number  of  selected 
cases,  and  feel  that  Dr.  Bassler  has  not  claimed  too  much 
for  it.  Apart  from  any  real  therapeutic  effect  it  may  pos- 
sess, it  certainly  exerts  a  powerful  psychic  influence,  and 
few  there  are,  who  after  being  electrically  vibrated  for  a 
time,  do  not  report  tangible  sensations  of  braced  and 
steadied  nerves,  plus  a  much  more  comfortable  abdominal 
feeling. 

Massage  Roller. — This  consists  of  a  revolving  cylinder, 
which  can  be  filled  with  hot  or  cold  water,  and  which  is 
furnished  with  a  battery  attachment.  Heat  or  cold,  or 
with  an  instrument  attached  to  each  battery  pole,  alter- 
nating heat  and  cold,  combined  with  electricity,  may  be 
applied. 

This  method  can  be  employed  to  advantage  in  chronic 
constipation  from  atonic  intestinal  musculature,  in  the 
dragging-down  feeling  accompanying  relaxed  visceral  sup- 
ports, in  vague  abdominal  pains  so  bitterly  complained  of 
by  neurasthenics,  and  in  epigastralgia. 

Turck's  Gyromele. — Dr.  Fenton  B.  Turck,  of  New  York, 
has   devised   an  ingenious  instrument,   which  he  calls  a 


TURCK  S    GYROMELE  215 

gyromele,  and  which  is  intended  for  local  treatment  of  the 
stomach.  It  consists  of  a  cable  with  a  sponge  attachment, 
which  can  be  made  to  revolve  within  an  outer  stomach- 
tube.  This  revolving  sponge  can  be  spun  around  in  the 
stomach  with  greater  or  less  rapidity  and  the  sensations 
elicited  are  described  by  the  patients  as  weird  in  the  extreme. 
There  is  an  arrangement  connected  with  the  gyromele 
whereby  medicated  fluids  can  flow  into  the  stomach  through 
the  outer  tube,  and  also  an  attachment  by  which  it  can  be 
connected  to  a  battery  and  an  electric  current  sent  into  the 
stomach  while  the  sponge  is  rotating.     Turck  advocates 


Fig.  51. — Turck's  gyromele. 

its  use  in  catarrhal  gastritis  to  cleanse  the  mucous  mem- 
brane, or  in  atonic  stomachs  of  poor  motor  power  for  general 
cleansing  purposes.  It  has  not  come  into  wide  use,  and  I 
would  hesitate  to  recommend  it.  Its  inventor  claims  that 
he  has  obtained  some  most  satisfactory  results  from  its 
intelligent  employment. 

Local  Counter-irritation  over  the  Epigastrium  or  Abdo- 
men.— In  many  of  the  painful  and  acute  disorders  of 
digestion,  as  well  as  in  some  of  the  chronic  affections,  not 
only  amelioration  of  the  painful  symptoms  may  be  obtained 
by  counter-irritation,  but  actual  curative  results. 

The  entire  basis  for  the  employment  of  counter-irritation 
rests  upon  reflex  action,  or  the  conduction  of  a  nervous 
impulse  to  a  center  which,  when  so  stimul  ated,  sends  out  an 
impulse  to  the  part  of  the  body  which  is  diseased. 

The  indications  for  counter-irritation  in  this  class  of  dis- 


2l6  VARIOUS  METHODS  OF  TREATMENT  OF  THE  STOMACH 

orders  are  three — for  the  rehef  of  pain;  for  favorably- 
affecting  inflammations  or  congestions;  and  for  causing 
the  absorption  or  removal  of  inflammatory  deposits  after 
the  active  inflammation  has  ceased. 

For  acute  pain  in  the  stomach  or  abdomen  the  surface 
may  be  quickly  reddened  by  the  local  application  of  chloro- 
form, having  a  handkerchief  or  cloth  saturated  with  it,  and 
covering  the  cloth  with  another  to  keep  out  the  air.  As  one 
area  gets  too  hot,  the  handkerchief  may  be  removed  from 
place  to  place,  and  often  this  will  be  sufficient  to  relieve  an 
acute  epigastralgia.  Not  quite  so  prompt,  but  perhaps 
more  efficacious  is  a  mustard  plaster,  made  by  mixing  pow- 
dered mustard  with  warm  vinegar  or  water,  plastering  it 
over  cloth  or  paper,  and  applying  it  to  the  desired  spot. 
Should  it  be  advisable  to  weaken  the  plaster,  this  can  be 
done  by  the  addition  of  a  varying  amount  of  flour  while  it 
is  being  mixed.  This  mustard  plaster  can  remain  on  until 
the  skin  is  well  reddened,  or,  if  wished,  until  a  blister  is 
produced.  When  it  is  not  desired  that  the  mustard 
should  be  applied  directly  to  the  skin,  the  plaster  proper  can 
be  covered  with  a  thin  piece  of  linen  or  cheese-cloth,  which 
will  to  an  extent  protect  the  skin.  There  are  also  ready- 
prepared  mustard  plasters  which  are  easily  procurable,  and 
can  be  cut  into  any  shape  or  size  indicated,  moistened  and 
applied  to  the  needed  location. 

Among  other  methods  of  using  gentle  counter-irritation 
and  heat  to  the  surface  are  poultices,  made  from  various 
materials,  such  as  meal,  tender  leaves  of  plants  or  trees, 
kaolin  or  feldspar.  The  last  named  has  been  exploited  in 
this  country  to  a  stupendous  degree  and  has  a  wide  sale  at 
an  exorbitant  price,  but  in  reality  has  no  more  virtue  than 
any  other  poultice.  The  heat  and  moisture  contained  in 
poultices  produce  the  good  effects  and  they  should  be  fre- 
quently changed,  so  that  both  these  properties  may  be 
present  at  all  times  they  are  used.  Nothing  is  more  useless 
or  irritating  than  a  cold  or  dry  poultice. 

Turpentine  stupes  are  often  helpful,  and,  when  kept  hot 


LOCAL   APPLICATIONS  217 

and  moist  like  poultices,  possess  all  the  virtues  of  the  latter 
plus  the  counter-irritating  effect  of  the  turpentine. 

Hare  highly  recommends  the  spice  plaster  as  an  eligible 
poultice  in  abdominal  discomfort.  This  is  made  by  mixing 
equal  parts  of  allspice,  cloves,  cinnamon  and  nutmegs,  and 
adding  thereto  one-half  part  of  black  pepper.  These  con- 
stituents are  made  into  a  homogeneous  mass  by  using  a 
knife-blade  to  mix  them,  and  are  then  sewed  in  a  bag, 
which  is  quilted  to  prevent  sagging  of  its  contents.  One 
side  of  the  poultice  is  now  wetted  with  warm  brandy, 
whiskey  or  vinegar  and  appHed  to  the  part  desired.  If  the 
skin  is  tender,  the  proportion  of  the  pepper  or  cloves  should 
be  decreased.  This  plaster  may  be  allowed  to  remain  over 
the  affected  part  for  hours  or  even  days,  provided  it  is 
frequently  moistened,  and  is  quite  useful  in  the  treatment  of 
chronic  gastric  catarrh  and  abdominal  discomfort.  It  is 
also  grateful  to  those  dainty  neurasthenics,  who  abhor  a 
sticky  poultice,  or  whose  olfactories  will  not  bear  with  com- 
fort a  turpentine  stupe.  These  patients  will  find  the  spice 
poultice  pleasant  to  use,  cleanly  to  manipulate,  and  mildly 
counter-irritant  and  analgesic  in  its  effects. 

There  are  numerous  methods  of  applying  plain  or  dry 
heat  to  the  abdomen,  some  of  them  quite  simple,  but  none 
the  less  efficacious.  A  plain  rubber  hot-water  bag  can  be 
found  in  nearly  every  household  and  will  always  be  grate- 
ful in  its  effects,  when  not  too  full  of  water,  and  therefore  too 
heavy.  When  the  bag  is  not  convenient,  a  porcelain  plate 
may  be  heated  over  a  lamp  or  gas  jet,  and  quickly  applied 
over  a  painful  area.  I  have  also  seen  tin  buckets  or  pans 
filled  with  hot  water  and  brought  into  use  for  local  counter- 
irritation,  when  no  other  means  were  at  hand. 

There  are  a  number  of  agents  which  are  useful  in  abating 
pain  or  soreness  in  the  abdomen  when  either  painted  on  or 
rubbed  in.  Tincture  of  iodine  alone,  or  diluted  with  one 
part  of  tincture  of  belladonna  to  three  of  the  iodine  is  an 
eligible  local  application.  I  order  it  painted  on  with  a 
camel  hair  brush,  making  several  applications  as  each  coat 


2l8  VARIOUS  METHODS  OF  TREATMENT  OF  THE  STOMACH 

dries.  It  seldom  burns  the  first  time,  but  after  several 
"paintings"  have  been  applied,  it  burns  energetically. 
This  may  be  applied  once  daily  for  three  or  four  times,  and 
then  it  will  be  necessary  to  leave  it  off  for  several  days  until 
the  epidermis  peels  off.  Iodine  seldom  blisters,  but  the 
epidermis  desquamates,  leaving  quite  a  tender  surface, 
which  requires  several  days  to  become  normal.  For  chronic 
abdominal  soreness  or  tenderness,  the  iodine  is  beneficial, 
but  is  not  prompt  enough  in  its  action  for  acute  affections. 

"Rubbing"  with  various  liniments  is  an  ancient  method, 
but  in  some  conditions  useful,  nevertheless.  There  are 
many  drugs,  pungent,  volatile  or  oily  that  are  of  use  in  this 
manner.  Turpentine,  chloroform,  capsicum,  menthol,  oil 
of  cloves  or  sassasfras  and  many  others.  Then  there  are 
ointments  of  vaseline  or  lanolin  as  a  base  that  have  in  them 
capsicum  or  menthol  and  are  quite  efficacious  when  applied 
locally.  There  is  at  present  on  the  market  an  ethical 
preparation,  called  methyl  salicylate  ointment,  which 
comes  in  a  collapsible  tube.  This  can  be  rubbed  over  the 
surface  ad  libitum,  and  often  affords  relief  to  either  acute 
or  chronic  pains. 

Another  point  to  be  considered  in  the  use  of  local  applica- 
tions or  liniments  in  gastrointestinal  disorders  is  the  fact 
that  it  gives  the  patient  or  attendants  something  to  do, 
and  when  something  is  being  constantly  or  frequently  done, 
there  is  a  more  satisfied  frame  of  mind,  and  the  patient  can 
wait  with  more  equanimity  the  period  when  perhaps  more 
logical  measures  have  had  time  to  take  effect.  This  may 
be  considered  small  and  unimportant  by  some,  but  in  the 
management  of  this  class  of  cases,  nothing  that  promotes 
the  comfort  or  contentment  of  the  sufferer  should  be  over- 
looked. This  view  partially  includes  psychotherapeutic 
management,  and  will  be  discussed  at  length  in  a  subsequent 
chapter. 

The  Cannon  Ball. — This  has  been  advocated  as  a  form 
of  massage  peculiarly  suited  for  atonic  constipation.  The 
patient  lies  on  his  back,  and  rolls  the  ball  about  over  his 


ABDOMINAL   MASSAGE  219 

abdomen,  trying  in  a  general  way  to  follow  the  course  of 
the  colon.  Its  real  utility  is  doubtful,  but  it  is  not  liable  to 
inflict  any  damage,  and  it  may  serve  as  a  psychic  stimu- 
lant at  least  to  idle  and  neurasthenic  individuals,  who  need 
something  of  this  sort  to  keep  them  contented. 

Abdominal  Massage. — Views  as  to  the  efficacy  of  this 
means  of  treating  abdominal  disorders,  adhesions,  inflam- 
mations or  displacements  are  widely  divergent,  some  laud- 
ing and  some  condemning. 

As  to  massage  in  stomach  troubles  proper,  I  am  uncertain 
regarding  its  benefits.  I  have  employed  it  in  many 
instances  in  dilated,  stagnating  stomachs,  with  poor  motor 
power,  and  myasthenia,  and  have  been  disappointed  in 
results.  That  the  fault  was  not  in  the  application  was 
certain,  as  I  availed  myself  of  the  services  of  expert  and 
conscientious  masseurs,  and  am  sure  that  nothing  proper 
or  necessary  was  omitted.  One  case  that  afterward 
developed  malignancy  was,  I  fear,  made  worse  by  the 
manipulation. 

Except  in  somewhat  chronic  conditions,  where  there  is 
but  little  soreness,  and  there  seem  to  be  present  perigastric 
adhesions,  I  would  not  recommend  massage,  and  shall 
dismiss  it  with  this  brief  allusion,  as  unsuitable  for  gastric 
disorders.  Functional  troubles  of  the  stomach  will  prob- 
ably be  made  worse  by  its  use. 

In  the  intestinal  cases  of  chronic  atonic  constipation, 
relaxation  or  incompetence  of  the  abdominal  parietes, 
bearing-down  sensations  from  enteroptosis,  vague  neuralgic 
pains  from  dragging  and  torsion  of  the  intestines,  and  the 
cutting  and  "pulling"  pains  from  old  perienteric  adhesions 
— in  all  of  these  conditions  have  I  noted  apparent  benefit 
following  intelligent  and  persistent  massage. 

In  most  of  these,  there  were  also  employed  passive 
exercise  and  various  forms  of  scientific  gymnastics. 

Massage,  according  to  Boas,  is  contraindicated  in  all 
recent  cases  of  ulcer  with  adhesions,  in  which  cases  even  its 
cautious  application  may  cause  a  perforation  of  the  ulcer 


3  20  VARIOUS  METHODS  OF  TREATMENT  OF  THE  STOMACH 

and  consequent  disastrous  effects.  It  should  not  be  em- 
ployed in  any  acute  inflammatory  conditions  of  the  gas- 
trointestinal tract,  nor  in  any  acute  states  accompanied 
by  fever  or  excessive  accumulation  of  flatus.  I  might 
add  that  it  is  generally  accepted  that  massage  is  not  indi- 
cated in  conditions  of  accelerated  peristalsis,  or  where, 
upon  manipulation,  the  circular  muscular  fibers  of  the  intes- 
tines tend  to  assume  tetanic-like  contractions.  Malignant 
trouble,  or  the  presence  of  metastases,  or  when  the  test  for 
occult  blood  in  the  feces  is  positive,  contraindicate.  Boas 
also  advises  against  it  in  the  treatment  of  patients  above 
forty  years  of  age,  in  whom  the  symptoms  of  gastric  dis- 
eases have  appeared  suddenly,  unless  malignancy  can  be 
positively  excluded. 

A  detailed  description  of  the  many  methods  and  move- 
ments of  massage  is  not  feasible  in  a  work  of  this  scope,  as 
it  is  a  science  within  itself.  Briefly,  it  may  consist  of  rub- 
bing, kneading,  tapping,  or  rolling  motions,  beginning  at 
the  upper  part  of  the  abdomen,  and  following  the  general 
course  of  the  large  intestine,  descending.  The  small 
intestine  should  be  manipulated  as  well  as  the  abdominal 
muscles.  lUoway  recommends  massage  for  five  to  fifteen 
minutes  in  adults  and  three  to  five  minutes  in  children,  at 
least  every  other  day  for  a  period  of  six  weeks,  and  then  if 
there  is  improvement,  at  longer  intervals,  but  for  a  long 
period  of  time.  It  should  be  given  preferably  in  the  early 
morning  in  the  fasting  condition.  A  patient  can  practise 
automassage  in  the  following  manner:  Sitting  upright, 
with  the  right  hand  he  should  stroke  the  abdomen  from  the 
caput  coli  to  the  hepatic  fiexure,  and  then  along  the  trans- 
verse colon.  With  the  left  hand,  he  can  then  massage 
down  the  descending  colon.  Circular  stroking  movements 
should  then  be  made  over  the  median  abdominal  region. 
This  can  often  be  conveniently  carried  on  while  he  is  sitting 
on  the  toilet  endeavoring  to  have  his  morning  evacuation 
of  the  bowels.  The  massage  may  last  from  five  to  ten 
minutes. 


ABDOMINAL   MASSAGE  221 

Where  trained  massage  is  not  available,  gentle  rubbing 
or  kneading  with  hands  previously  warmed,  will  prove 
both  grateful  and  soothing,  where  there  is  no  acute  soreness. 
The  physician  can  give  directions  and  demonstrations 
sufficient  for  attendants  of  ordinary  intelligence  to  compre- 
hend and  carry  out,  and  though  no  brilliant  results  may  be 
attained,  patients  often  desire  it  and  claim  to  experience 
decided  relief  from  even  untrained  manipulation. 

Each  of  the  methods  mentioned  have  a  place  in  the  treat- 
ment of  gastrointestinal  disorders  and  some  particular  one, 
though  unimportant  in  itself,  when  properly  employed, 
may  spell  the  difference  between  success  and  failure  in  the 
management  of  a  discouraged  invalid. 


CHAPTER  IX 

ORTHOPEDIC  METHODS  OF  SUPPORTING  THE 
ABDOMINAL  WALLS  AND  VISCERA 

Before  and  since  the  advent  of  the  X-ray  in  diagnosis  it 
has  been  realized  by  many  thoughtful  observers  that  much 
comfort  could  be  given,  and  in  some  cases  absolute  relief, 
by  the  employment  of  proper  supportive  measures  in  gas- 
troptosis,  enteroptosis,  or  relaxed  and  incompetent  abdom- 
inal walls. 

As  to  the  latter  condition,  many  do  not  realize  the  malign 
influence  exercised  upon  the  orderly  functions  of  the  stom- 
ach and  intestines  by  flabby  and  incompetent  abdominal 
parietes. 

There  are  two  classes  of  individuals  in  whom  this  con- 
dition is  most  frequently  found:  middle-aged  or  elderly 
women,  who  have  borne  several  children  in  close  succession, 
and  whose  domestic  duties  have  so  pressed  them  that  they 
have  never  permitted  the  abdominal  walls  sufficient  quiet 
and  rest  to  bring  restored  tone;  the  other  class  includes 
elderly  men,  of  previously  strong  physique  and  liberal 
deposition  of  fat  in  the  abdominal  cavity  and  parietes,  who 
have  lapsed  into  feeble  health  from  any  cause.  Both  of 
these  classes  complain  of  a  sense  of  weight  and  ' '  dragging- 
down"  while  they  are  in  a  standing  position,  and  suffer 
from  many  indefinite  ailments,  which  may  to  some  extent 
be  traced  to  the  ptosed  viscera  and  the  lack  of  support  given 
by  the  abdominal  walls. 

I  have  under  observation  at  present  two  cases,  each 
representing  a  class.  One  a  woman  of  forty-eight,  the 
mother  of  seven"  children.  This  woman,  whose  circum- 
stances in  life  have  been  trying,  has  a  relaxed  and  pendu- 
lous abdomen,  which,  without  a  support  renders  her  almost 


KILMER  S   BELT  223 

helpless.  With  a  well-fitting  abdominal  supporter  she  can 
be  up  and  about,  attending  to  her  duties  with  comparative 
comfort.  The  other,  a  man  of  sixty-two  years,  weighing 
235  pounds,  with  a  rather  weak  and  degenerated  heart, 
finds  that  without  the  supporter  for  his  pendulous  and  bulky 
abdomen,  he  could  not  be  up  at  all  with  comfort. 

The  present-day  straight-front  corset  is  a  marked 
improvement  over  the  wasp-like  corsets  formerly  worn, 
and,  when  properly  fitted,  they  exert  a  really  helpful  sup- 
portive influence  upon  the  abdominal  walls  and  their  con- 
tained organs. 

Another  condition  to  which  undue  prominence  has  been 
given  is  the  "floating  kidney."  The  wave  of  surgical  zeal, 
during  which  every  palpable  kidney  was  "tacked  up" 
has  happily  passed,  and  we  now  understand  that  the  major- 
ity of  these  loose  kidneys  can  be  sufficiently  steadied  by 
outside  supports  to  afford  the  patient  relief  from  most  of 
the  symptoms  caused  thereby. 

In  persistent  and  uncontrollable  vomiting,  either  in  per- 
tussis, or  pregnant  women,  or  from  any  other  cause,  external 
abdominal  support  is  often  grateful,  and  efficaceous  in 
controlling  the  paroxysms. 

Some  years  ago  T.  W.  Kilmer  devised  a  belt  for  the  relief 
of  pertussis,  but  his  belt  has  found  a  larger  field.  The 
original  consisted  of  a  stockinet  band  applied  so  it  would 
extend  from  just  above  the  pubes  to  well  above  the  epi- 
gastrium. It  is  prevented  from  slipping  down  by  two  bands 
over  the  shoulders. 

Recently  Kilmer  has  reported  a  simplified  belt  made  of 
linen  with  strips  of  elastic  webbing  inserted  on  either  side, 
and  laced  up  the  back  like  a  corset.  The  belts  should  meas- 
ure 2  or  3  inches  less  than  the  circumference  at  the  umbili- 
cus, though  the  degree  of  constriction  should  be  gauged  to 
each  individual  case,  and  not  be  made  burdensome.  This 
belt  is  valuable  in  the  vomiting  of  seasickness  and  nervous 
vomiting,  and  is  prized  by  some  as  an  abdominal  supporter 
also.     The  cost  is  slight,  and  I  have  in  a  number  of  instances 


224       SUPPORTING   THE   ABDOMINAL   WALLS   AND  VISCERA 

had  them  made  at  home  by  some  female  member  of  the 
family. 

In  nearly  every  city  can  be  found  makers  of  abdominal 
belts,  who  can  so  fit  and  adjust  them  that  material  support 
is  afforded.  In  addition  to  the  support,  an  amount  of 
counter-pressure  is  exerted,  which  prevents  to  some  extent 
the  evil  effects  of  gravity  in  producing  a  lowered  blood  pres- 
sure when  the  patient  stands.  In  order  that  the  belt  may 
serve  its  purpose,  the  physician  should  note  whether  or  not 
it  is  well  fitting  and  really  supports.  Most  of  the  belts  that 
are  kept  in  stock  by  the  instrument  and  wholesale  drug 
houses  are  simply  broad  elastic  belts,  surrounding  the  hips, 
and  pressing  backward  upon  the  abdominal  walls  without 
any  traction  upward. 

The  illustration  of  Dr.  Lockwood's  belt  shows  one  which 
serves  the  desired  purpose.  This  belt  is  so  constructed  that 
it  lies  low  in  front,  and  rises  high  in  the  back,  so  that  pres- 
sure is  not  only  backward  but  upward.  Perineal  straps 
seem  to  be  necessary,  as  otherwise  the  belt  rides  up  in  front, 
yielding  nb  upward  traction.  Dr.  Lockwood  advises  that 
the  belt  be  adjusted  before  the  patient  rises  in  the  morning, 
so  as  to  retain  the  organs  as  far  as  possible  in  the  position 
which  they  assume  during  recumbency.  The  belt  should 
be  worn  continuously  during  the  day.  If  it  is  well  fitted, 
the  use  of  hernial  pads,  to  which  so  many  patients  strenu- 
ously object,  may  be  dispensed  with. 

Some  well-fitting  straight-front  corsets  are  fitted  with  an 
inner  belt  of  elastic  webbing,  which  greatly  augments  their 
supportive  efficiency.  In  these,  however,  as  in  all  devices 
for  holding  up  prolapsed  organs  and  incompetent  walls,  the 
principle  of  upward  and  not  horizontal  pressure  must  be 
kept  in  mind. 

Pads  of  various  kinds,  shapes  and  sizes  are  used  as 
accessories  to  these  various  belts  and  corsets,  many  of 
which  are  a  detriment  instead  of  an  aid.  Many  are  devised 
with  the  idea  of  holding  in  position  a  floating  kidney,  and 
have  an  extra  pad  fixed  to  some  part  of  the  belt,  or  slipped 


SUPPORTIVE   CORSETS 


225 


loosely  inside  of  it,  depending  on  the  tight  constriction  of 
the  encircling  band  to  hold  it  in  place. 

Most  of  these  are  worse  than  useless,  acting  in  some  cases 
like  the  ill-fitting  truss  that  not  only  fails  to  confine  the 
hernia,  but  keeps  it  forced  outside  the  canal.  I  have  never 
yet  seen  a  kidney  really  steadied  or  kept  in  place  by  one 


"I/" 

* 

4K    ^' 

li    lu.t  ,^. 

Fig.  52. — Bassler's  corset  on  an  extreme  case  of  gastroptosis  in  a  medium- 
sized  young  woman  in  whom  the  corset  raised  the  pyloric  portion  of  her  stomach 
eight  centimeters  with  almost  immediate  relief  of  the  gastric  distress  after 
eating,  complete  relief  of  constipation,  and  marked  subsequent  benefit  to  her 
general  health. 


of  these  pads,  nor  have  I  seen  a  ptosed  stomach  raised 
one  iota  by  their  employment. 

Of  some  use  to  men  or  women  with  pendulous  or  incom- 
petent abdominal  parietes,  and  who  cannot  afford  to  have 
properly  fitted  bandages  or  corsets  adjusted,  is  a  large- 
15 


2  26       SUPPORTING   THE   ABDOMINAL   WALLS   AND  VISCERA 

sized  pad,  which  fully  and  adequately  covers  the  whole 
lower  abdomen,  and  can  be  worn  under  a  belt  or  a  straight- 
front  corset.  Bassler  has  used  with  satisfaction  in  such 
patients  a  pad  made  of  thin  but  sufficiently  stiff  leather  to 
give  it  form,  and  on  which  the  side  next  to  the  abdomen 
is  a  cushion  of  curled  horsehair  covered  with  kid. 


Fig.  53. — Bassler's  corset  with  medium  curvature  on  a  case  of  gastroptosis 
with  palpable  and  movable  right  kidney  in  a  very  slim  woman,  who  was  5  feet 
1 1  inches  in  height  and  weighed  no  pounds.  The  pyloric  extremity  of  her  stom- 
ach was  raised  five  centimeters,  with  relief  of  her  gastric  symptoms  and  a  gain 
in  her  general  health  and  weight  amounting  to  12  pounds  in  the  first  2  months, 
and  17  pounds  in  5  months. 


I  have  modified  this  by  using,  instead  of  the  horsehair, 
cotton  batting,  and,  instead  of  the  kid,  several  thicknesses 
of  cotton  flannel. 

The  lower  edge  of  this  pad  fits  into  and  just  above  the 
arch  made  by   the   anterior   superior   spines   of  the  ilia. 


SUPPORTIVE    CORSETS  227 

Poupart's  ligament,  and  the  umbilicus,  and  the  lateral 
edges  well  over  the  sides  of  the  abdomen.  The  cushion 
is  thicker  at  its  lower  edge  than  above;  it  is  soft  and  pliable, 
and  readily  adjusts  itself  to  the  body  and  outside  support. 
It  is  quite  comfortable  to  wear,  though  rather  warm  for 
summer  use.  It  can  be  fastened  securely  inside  of  the  belt, 
or  one  half  of  it  can  be  attached  to  one  side  of  the  corset. 
Usually  with  ordinary  corsets  or  with  a  tight -fitting  belt 
it  remains  well  in  place. 

When  the  circumstances  of  a  female  patient  permit 
intelligent  fitting  of  a  corset,  the  following  facts  should  be 
borne  in  mind:  It  should  be  long  enough  to  come  well 
down  over  the  pubic  bone  and  outward  curve  of  the  hips, 
should  not  extend  too  high  on  the  thorax,  should  be  loose 
enough  above  the  level  of  the  umbilicus  to  allow  full  play 
to  lungs,  diaphragm  and  other  organs  that  move  with 
respiration,  and  should  give  to  the  wearer  an  actual  sense 
of  comfort,  support  and  restfulness.  Any  corset  that  ex- 
erts a  constriction  at  or  near  the  epigastric  region  interferes 
with  the  normal  change  in  size  and  position  of  the  stomach 
when  it  is  distended  with  food,  and  by  this  baneful  pressure 
causes  either  a  crowding  or  displacement  of  other  adjacent 
organs.  Pressure  at  the  sides  rather  low  down  on  the 
thorax  may  be  allowed  with  safety,  but  such  narrowing 
should  be  allowed  for  by  a  corresponding  increase  in  the 
anterior  dimensions  of  the  corset. 

Women  present  infinite  variations  in  the  contour  and 
size  of  their  bodies,  and  corsets  should  be  made  to  suit  with 
exactness  each  individual  figure. 

Gallant,  of  New  York,  has  suggested  a  corset  built  on  the 
lines  of  a  perfectly  fitting  garment.  This  is  quite  stylish, 
and  for  that  reason  particularly  liked  by  most  women,  but 
in  many  instances  it  fits  too  tightly  over  the  hips,  as  it 
binds  the  lower  body  and  squeezes  the  flabby  subcutaneous 
tissue  found  in  many  of  those  who  have  lived  well  and 
exercised  but  little. 

Corsets,    belts    and    abdominal    supporters,    and    other 


2  28       SUPPORTING    THE    ABDOMINAL   WALLS    AND  VISCERA 

devices  along  these  lines  have  their  proper  and  useful  place 
in  persons  of  generous  proportions,  or  those  with  full  or 
protruding  abdomens.  There  is  another  class,  however, 
in  which  all  these  devices  are  utterly  without  benefit,  and 
in  whom  the  best-fitted  corset  or  abdominal  supporter 
would  afford  no  good  service  in  lifting  prolapsed  organs. 

Take  the  slender  unmarried  women,  or  the  slim  and 
medium-built  individuals,  with  abdomens  absolutely  flat, 
and  hips  almost  on  a  line  with  the  smallest  part  of  the  waist, 
or  those  emaciated  individuals,  who  have  perhaps  been  on  a 
rigorous  diet  for  many  months,  and  who  present  a  depres- 
sion where  a  rounded  contour  should  be.  These  are  not 
fit  subjects  for  abdominal  supporters,  though  many  of 
them  suffer  from  the  most  pronounced  forms  of  gastroptosis 
and  enteroptosis,  and  few  there  are  in  whom  it  has  been 
found  that  properly  adjusted  bandages  of  adhesive  plaster 
do  not  exert  a  tangible  and  beneficent  effect. 

To  Dr.  Achilles  Rose,  of  New  York,  must  we  accord 
credit  for  the  first  useful  and  scientific  method  of  applying 
adhesive  plaster  for  supportive  purposes.  Kemp  first 
suggested  zinc  oxid  plaster  on  moleskin,  and  made  some 
modifications  in  the  method  of  applying  the  "Rose  belt," 
which  added  to  its  efficiency.  After  applying  many  of 
these  belts,  I  have  found  that  several  small  reinforcing 
pieces  of  the  plaster  still  further  enhance  their  usefulness, 
and  the  completed  method,  as  now  employed,  will  be  pres- 
ently described. 

As  in  practically  all  appliances  of  worth  there  are  certain 
disadvantages,  this  is  no  exception,  and  they  will  be  men- 
tioned first.  The  adhesive  plaster,  having  to  remain 
constantly  in  place,  prevents  thorough  bathing,  which  in 
itself  is  a  deprivation  to  many  people.  In  hot  weather, 
and  with  some  in  any  weather,  there  comes  on  the  surface 
of  the  skin  covered  by  the  bandage  an  almost  intolerable 
itching,  which,  in  nervous  individuals,  is  a  serious  matter. 
Some  skins  are  so  sensitive  that  the  adhesion  and  tension 
of-  the  bandage  brings  about  quite  a  severe  dermatitis,  and 


THE    ROSE   BELT  229 

occasionally  there  occurs  a  localized  infection  in  the  hair 
follicles,  which  may  produce  a  number  of  small  but  painful 
furuncles.  Lastly,  I  have  encountered  a  few  neurotic 
invalids,  or  "pseudo-invalids,"  who,  claiming  that  the  ever- 
present  constriction  made  them  excessively  nervous,  com- 
plained continually  until  it  was  removed. 

The  advantages  of  this  appliance  lie  in  the  fact  that  it  can 
be  accurately  adjusted  to  the  most  slender  person,  that  it 
holds  its  position  constantly,  and  that  steady  upward 
traction  can  be  maintained  with  a  minimum  of  discomfort. 

It  should  be  applied  as  follows:  Zinc  oxid  adhesive 
plaster  on  moleskin  6  or  7  inches  wide,  the  latter  being  for 
taller  patients,  should  be  employed.  A  measurement  may 
be  taken  of  the  waist,  and  the  plaster  cut  i  or  2  inches  longer 
than  this  measurement.  The  plaster  is  laid  in  its  central 
part  over  the  lower  abdomen,  and  two  curved  lines,  as 
indicated  by  the  illustration,  are  drawn,  these  lines  clearing 
in  a  curved  line  the  crests  of  the  ilia.  This  point  should  not 
be  overlooked,  lest  the  plaster  impinge  on  these  bony 
prominences,  causing  considerable  irritation  thereby.  The 
lateral  pieces  are  narrowed  slightly,  and  are  used  to  rein- 
force the  main  piece  of  the  plaster. 

The  patient's  abdomen  is  cleaned,  first  with  water  and 
soap,  then  with  alcohol  or  chloroform,  as  otherwise  the 
oleaginous  secretions  present  on  the  surface  would  lessen 
the  adhesive  power  of  the  covering.  The  upper  part  of  the 
pubes  is  shaved  (it  is  not  necessary  to  shave  the  whole  of 
the  pubes),  and,  if  there  is  any  hair  on  the  abdomen,  that 
should  be  shaved  also. 

In  application  of  the  bandage,  I  endeavor  to  have  the 
hips  so  elevated  that  the  body  and  limbs  assume  almost,  if 
not  quite,  an  angle  of  45  degrees.  This  is  accomplished  by 
placing  under  the  buttocks  an  ordinary  porcelain  wash- 
basin or  other  vessel,  upside  down,  with  a  thin  towel 
between  the  naked  skin  and  the  cold  surface  of  the  basin. 
The  patient  is  instructed  to  relax  the  abdominal  muscles, 
and  the  operator  may  with  gentle  downward  manipulation, 


230       SUPPORTING   THE   ABDOMINAL   WALLS    AND  VISCERA 

aided  by  gravitation,  press  the  formerly  prolapsed  organs 
out  of  the  lower  abdomen  into  the  upper.  The  bandage  is 
then  applied,  and  by  gentle  but  firm  stroking  is  closely 
adapted  to  the  surface  of  the  skin  all  around  the  body,  care 
being  taken  to  avoid  wrinkles.  The  reinforcing  pieces  are 
then  put  on,  letting  them  begin  down  near  the  center  of  the 
most  dependent  part  of  the  abdomen,  and  extending  around 
the  waist  line  in  an  upward  direction.  As  these  sharp  ends 
do  not  generally  quite  meet  in  the  back,  it  is  well  to  let  a 
short  piece  of  the  plaster  extend  well  over  each  end,  thus 
binding  them  together,  and  greatly  adding  to  the  efficiency 
of  the  whole  bandage.  Also  in  front,  where  the  several 
parts  of  the  bandage  superimpose  each  other,  the  addition  of 
a  few  small  pieces  will  prevent  later  slipping,  keeping  the 
whole  bandage  intact  for  a  much  longer  period. 

To  avoid  irritation  of  the  umbilicus,  some  advise  that  a 
notch  be  cut  out  where  the  bandage  covers  that  part  of  the 
anatomy.     This  I  have  seldom  found  necessary. 

The  bandage  should  remain  on  as  long  as  it  is  tight  and 
efficient,  and  by  the  occasional  use  of  small  reinforcing 
pieces,  where  it  is  inclined  to  give  way  or  become  loosened, 
it  will  serve  its  purpose  much  longer.  Three  or  four  weeks 
is  the  average  life  of  a  Rose  belt,  though  Kemp  claims  that 
many  of  his  last  six  weeks. 

To  remove  the  bandage,  it  may  be  softened  by  applying  a 
10  per  cent,  ointment  of  wintergreen  at  night,  and  the  fol- 
lowing morning  it  will  come  off  easily.  The  removal  may 
also  be  facilitated  by  applying  at  the  time  either  oil  of  win- 
tergreen, ether,  or  gasoline. 

After  the  belt  has  been  removed,  if  there  is  irritation,  the 
skin  should  be  thoroughly  bathed  with  soap  and  warm 
water,  then  gently  rubbed  with  alcohol,  and  well  dusted 
with  talcum  powder.  The  application  of  the  alcohol  and 
talcum  may  be  repeated  several  times  daily  with  benefit, 
if  it  is  desired  to  reapply  the  plaster  speedily.  When  it  is 
intended  to  put  on  another  Rose  belt,  an  interval  of 
twenty-four  or  thirty-six  hours,  seldom  more,  is  sufficient. 


THE    ROSE   BELT  23 1 

Where  it  is  not  practicable  to  obtain  the  wide  plaster,  a 
number  of  narrow  strips  may  be  used  up  to  the  required 
width,  making  a  fairly  good  substitute. 

Dr.  Rosewater  has  advocated  the  employment  of  a 
strip  of  zinc  oxid  plaster  2  or  3  inches  wide  and  of  sufficient 
length,  which  is  fastened  to  the  abdomen  just  above  the 
pubes.  This  is  drawn  upon  upward,  and  fastened  above  to 
the  lower  end  of  the  sternum.  Diagonal  strips  crossing  the 
lower  end  of  the  vertical  strip,  overlapping  behind  at  the 
spine,  are  then  applied.  A  horizontal  strip  is  fastened  to 
one  hip  and  stretched  across  the  pubes  to  the  other  hip, 
overlapping  the  ends  of  the  other  plaster,  and  acting  as  an 
additional  girdle. 

Numerous  modifications  of  the  various  methods  of  strap- 
ping have  been  suggested.  Some  have  apphed  the  plaster 
to  the  abdomen,  and  fastened  it  behind  by  tapes  running 
through  eyelet  holes,  so  as  to  loosen  the  constriction  at 
night.  Most  of  these  modifications  have  not  proved  help- 
ful, and  the  ones  described  may  be  considered  as  the  most 
practical  and  dependable. 

The  sense  of  strength,  comfort  and  general  well-being 
bestowed  by  a  well-adjusted  Rose  belt  is  sometimes 
remarkable.  It  has  been  demonstrated  in  many  instances 
by  the  X-ray  that  the  stomach  can  be  raised  and  held  up 
from  2  to  4  inches  above  its  former  level,  while  the  intestines 
are  also  raised  and  the  prolapsed  and  floating  kidney  or 
kidneys  materially  steadied.  Patients  whose  abdominal 
viscera  are  thus  supported  find  that  they  can  walk  erectly 
and  firmly,  and  lose  to  a  decided  extent  that  sense  of  drag- 
ging-down,  weakness  and  malaise  so  generally  present  in 
conditions  of  splanchnoptosis.  I  have  seen  several  who  for 
a  long  time  would  not  go  without  the  belt,  except  for  the 
brief  period  necessary  to  quiet  the  irritative  dermatitis. 

While  the  belt  is  on  every  effort  should  be  exerted  toward 
the  deposition  of  fat  in  the  abdomen,  as  well  as  other  parts 
of  the  body.  A  liberal  and  well-balanced  dietary,  coupled 
with  requisite  rest  and  other  helpful  influences  will  often 


232        SUPPORTING   THE   ABDOMINAL   WALLS   AND  VISCERA 

enable  these  weak  and  melancholy  semi-invalids  to  put  on 
an  amazing  amount  of  adipose  tissue,  which  in  itself  will 
steady  and  support  the  ptosed  and  poorly  supported 
viscera,  while  the  general  bodily  strength  will  indirectly 
bestow  tone  to  the  flabby  and  relaxed  abdominal  parietes. 

Often,  also,  I  have  observed  stubborn  constipation, 
evidently  due  to  ptoses,  kinks  and  torsion  of  the  intestines, 
give  way  with  surprising  quickness  after  the  application  of  a 
well-adjusted  Rose  belt. 

This  method,  apart  from  the  inconvenience  previously 
mentioned,  is  both  scientific  and  safe,  and  is  commended  as 
worthy  of  trial  in  all  cases  of  gastroptosis,  enteroptosis  or 
nephroptosis  in  slender  or  emaciated  patients.  It  can  do 
no  harm,  and  will  more  probably,  especially,  if  properly 
adjusted,  bestow  a  decided  amount  of  comfort  and  actual 
benefit. 


CHAPTER  X 
LOCAL  TREATMENT  OF  THE  INTESTINES 

Concerning  the  examination  of  the  lower  intestinal 
tract,  the  same  may  be  said  as  of  that  of  the  feces — it  is 
too  infrequent  and  cursory. 

There  are  several  reasons  for  this  unfortunate  state  of 
affairs:  For  many  years  diseases  of  the  rectum  and  lower 
bowel  have  not  been  looked  upon  by  the  general  practi- 
tioner or  internist  as  within  the  limits  of  his  legitimate  field. 
He  is  inclined  to  leave  them  to  the  surgeon  or  rectal  special- 
ist. Then,  too,  the  medical  profession,  as  a  whole,  has 
never  been  properly  instructed  in  the  diagnosis  and  non- 
surgical treatment  of  this  class  of  diseases,  most  of  the 
lectures  and  available  literature  dealing  with  the  surgical 
aspect  in  its  most  radical  sense.  Furthermore,  many 
physicians  consider  a  rectal  examination  as  a  procedure 
disagreeable  to  them  and  repulsive  to  the  patients. 

Answering  the  above,  I  may  say  from  personal  observa- 
tion and  experience  that  there  are  many  pathologic  condi- 
tions of  the  lower  bowel  not  calling  for  surgery,  but  which 
can  be  alleviated  or  cured  by  non-surgical  means;  that 
the  rectum  under  fairly  normal  conditions  is  not  filthy; 
and  that  the  vast  majority  of  patients  both  welcome  and 
appreciate  a  thorough  rectal  examination.  Few  indeed 
there  are,  either  male  or  female,  who,  upon  being  told  of 
the  advisability  of  such  an  investigation,  enter  any 
objection. 

The  indifference  and  neglect  of  this  branch  of  therapeutics 
by  the  rank  and  file  of  the  profession  has  sent  many  a 
sufferer  into  the  clutches  of  the  quack  and  the  charlatan, 
and  has  lost  to  the  regular  physicians  many  a  patient  who 
should  have  rightly  been  treated  by  them. 

233 


234 


LOCAL   TREATMENT   OF   THE   INTESTINES 


The  proper  examination  of  the  lower  bowel  will  be 
briefly  covered. 

A  thorough  examination  implies  inspection  of  the  ex- 
ternal and  internal  parts,  the  latter  with  the  aid  of  a  suitable 
speculum,  combined  with  a  careful  exploration  of  the  in- 
terior with  the  forefinger.  The  patient  should  not  lie  on 
the  back,  but  on  the  side,  with  the  legs  moderately  flexed, 
the  exposure  in  this  position  being  but  slight. 


Fig.  54. — Allison  physicians'  table,  No.  36.  Especially  adapted  to  the  needs 
of  rectal  therapeutics,  separable  leg  rests  furnish  support  to  patients  in  the  Sims 
position.  Foot  stool  and  waste  receptacle.  Top  covered  with  corrugated  rub- 
ber; contains  removable  metal  waste  receptacle.  Adjustable  operator's  stool. 
Made  by  the  W.  D.  Allison  Co.,  Indianapolis. 

An  inspection  of  the  external  parts  will  enlighten  the 
observer  as  to  the  general  appearance,  color  and  contour; 
the  presence  of  external  hemorrhoids,  skin  tabs  or  other 
growths;  abrasions  due  to  scratching,  flssures,  eczema, 
syphilitic  eruptions,  external  openings  of  flstulas,  marginal 
ulcers,  or  excoriations  from  a  discharge. 

Next  comes  the  digital  examination,  for  which  the  finger 
may  be  lubricated  with  lard  or  petrolatum.     It  is  best 


EXAMINATION   OF   RECTUM  235 

from  an  aseptic  standpoint  to  lubricate  the  finger  from  a 
tube.  In  inserting  the  finger,  it  should  be  pointed  slightly 
anteriorly  while  passing  the  sphincter  ani,  after  which  it 
should  be  directed  backward.  A  slight  rotary  motion  as 
the  finger  enters  will  facilitate  its  progress.  This  digital 
manipulation  will  inform  the  physician  of  the  tone  of  the 
sphincters,  whether  relaxed,  constricted  or  hypertrophied ; 
or  if  there  is  painful  spasmodic  contraction.  The  presence 
of  an  anal  fissure  may  now  be  discovered,  and  in  some 
instances  the  whole  cause  of  an  obstinate  and  painful 
constipation  may  be  disclosed. 

As  the  finger  enters  the  rectum,  a  stricture  located  within 
its  reach  would  be  encountered.  The  condition  of  the 
rectal  ampulla  should  be  noted,  whether  the  mucous 
membrane  is  moist  or  wet,  or  gathered  into  doughy  folds, 
indicating  a  catarrhal  condition  with  hypertrophy.  If 
the  membrane  is  dry  and  harsh,  with  here  and  there  small 
particles  of  dry  feces,  it  is  an  evidence  of  atrophy,  or  at 
least  serious  interference  with  the  normal  secretions  of  the 
parts.  Ulcerated  spots  or  clean-cut  ulcers  may  be  recog- 
nized in  most  instances,  likewise  the  presence  of  a  polypus. 
Hemorrhoids  may  sometimes  be  felt,  but  not  so  readily  as 
one  would  suppose,  considering  their  prominence  when 
protruded,  or  when  seen  through  an  instrument  that  affords 
some  degree  of  compression  to  the  tissues  surrounding  them. 
The  hard,  tortuous  tract  of  a  fistula  can  be  felt,  when  its 
course  runs  close  to  the  rectum.  When  examining  men  it 
is  good  practice  to  palpate  the  prostate  before  withdrawing 
the  finger.  After  withdrawing  the  finger,  it  should  be 
examined  for  blood,  mucus,  or  shreds  of  tissue,  noting  also 
if  the  peculiar  odor  of  malignant  disease  is  in  evidence 
(Albright). 

Instrumental  Examination. — The  prerequisites  for  a 
satisfactory  ocular  examination  are  good  light  and  a 
properly  constructed  speculum.  When  obtainable,  sun- 
light is  always  best.  Gas  also  furnishes  a  satisfactory 
light  when  augmented  by  the  incandescent  mantle  now  in 


236 


LOCAL   TREATMENT    OF    THE   INTESTINES 


use  and  sent  into  the  rectum  by  means  of  a  reflector 
placed  in  the  rear  of  the  operator.  Electricity,  too,  is  now 
easily  obtained,  and,  where  there  is  no  street  current 
available,  a  good  light  may  be  readily  obtained  from  a  dry- 
cell  battery.  Many  use  the  electric  head-light,  as  is 
employed  by  the  rhinologists  and  aurists.     For  high  rectal 


examinations  the  pneumatic  proctoscope,  with  the  same 
means  of  illumination,  is  satisfactory.  This  instrument 
permits  of  an  inflation  of  the  rectum  with  air,  while  in 
situ,  thus  permitting  a  thorough  inspection  of  the  walls. 

All  instruments  should  be  warmed  before  inserting  them 
into  the  bowel,  as  apart  from  giving  the  patient  an  un- 


EXAMINATION    OF    RECTUM 


237 


pleasant    sensation,    cold  instruments   are   provocative  of 
spasm  of  the  parts. 

There  are  numberless  rectal  specula,  many  of  which  vary- 
in  only  minor  particulars.     As  the  best  which  has  come  to 


Fig.  56. — Brinkerhoff's  rectal  speculum, 
length  4  inches,  outside  diameter  -J  inch. 


Fig.  58. — Brinkernoff's    rectal   speculum, 
length  5  inches,  outside  diameter  i|  inch. 


my  notice,  and  which  I  used  practically  to  the  exclusion  of 
others  is  the  Brinkerhoff  speculum,  which  is  conical, 
tubular  in  form,  and  with  a  removable  slide  through  which 


238 


LOCAL   TREATMENT   OF   THE   INTESTINES 


the  interior  of  the  rectum  can  be  readily  brought  into  view. 
They  run  in  different  lengths,  and  Jamison  has  had  some 
special  sizes  made  as  long  as  lo  inches.  This  speculum 
may  also  be  obtained  with  an  electric  light  attachment. 
G ant's  bivalve  examining  speculum  is  useful,  where  it  is 
desired  to  dilate  the  external  parts  rather  widely. 

In  examination  for  rectal  disease,  the  patient  should  lie 
on  either  side  with  the  legs  flexed,  and  supported  on  a 
wing  of  the  table. 


Fig.  59. — Albright's  small  hard-rubber  rectal  irrigator. 


Fig.  60. — Albright's  large  hard-rubber  rectal  irrigator. 

In  using  the  sigmoidoscope  a  certain  amount  of  both 
skill  and  patience  is  required.  It  is  important  that  the 
sigmoid  should  be  empty,  and  this  is  seldom  the  case  unless 
the  portion  of  the  gut  has  been  previously  flushed  out. 
Laxatives  are  unsuitable,  as  after  their  employment,  the 
sigmoid  is  apt  to  be  full  of  liquid  feces,  or  some  is  liable  to 
descend  during  the  course  of  the  examination. 

An  anesthetic  is  seldom  necessary.  The  knee-chest 
position  is  best,  but  in  women  who  object  to  this  position, 
the  sigmoidoscope  may  be  passed  with  the  patient  on  the 
left  side  in  an  exaggerated  Sims  position. 

The  instrument  having  been  warmed,  the  obturator  is 
placed  in  position,  and  the  whole  well  oiled.  It  is  also  help- 
ful to  inject  some  oil  into  the  rectum  and  to  thoroughly 


EXAMINATION   OF    THE    SIGMOID 


239 


240 


LOCAL    TREATMENT    OF    THE    INTESTINES 


anoint  the  anal  region.  The  sphincters  are  easily  passed, 
after  which  the  obturator  is  removed,  the  window  plug 
inserted,  the  air  bulb  and  electric  attachment  connected, 
and  the  light  turned  on.  The  inflation  is  now  gently- 
begun,  and  as  the  rectum  baloons  out,  the  instrument  is 
gradually  passed  upward  without,  if  possible,  touching  the 
rectal  walls.  Thus,  by  keeping  the  lumen  of  the  rectum 
well  in  sight,  and  dilating  it  in  advance  of  the  progressing 


Fig.  62. — Gant's  examining  speculum.  Fig.  63. — Pratt'sHbivalve  speculum. 


sigmoidoscope,  the  sigmoid  can  generally  be  entered  with- 
out pain  or  injury.  The  following  points  as  to  the  direction 
of  the  instrument  should  be  noted:  First,  it  should  point 
anteriorly,  until  the  sphincters  are  passed;  second,  it  follows 
the  coccygeal  curve  until  the  promontory  of  the  sacrum  is 
reached,  and  from  this  point,  third,  it  again  points  ante- 
riorly, rather  more  so  than  during  its  passage  through  the 
sphincters,  and,  as  the  desired  depth  is  reached,  the  outside 
portion  will  press  hard  against  the  posterior^commissure  of 


EXAMINATION   OF    THE    SIGMOID 


241 


the  anus.  The  point  of  greatest  difficulty  is  at  the  recto- 
sigmoidal  junction,  and  one  must  not  lose  sight  of  the  fact 
that  here  the  sigmoid  drops  to  the  left;  and  to  the  view  it 
appears  as  though  the  rectum  ended  in  a  blind  sac,  yet, 
by  sufficient  dilatation,  a  few  folds  may  be  seen  just  below 
the  end  of  the  instrument,  and  it  is  through  these  that  it 
must  pass  (Albright). 

Should  the  difficulty  continue,  the  patient  may  be  moved 
slightly,  or  the  upper  part  of  the  body  may  be  lowered,  so 
as  to  encourage  the  intestines  to  gravitate  somewhat  away. 
After  successfully  introducing  the  sigmoidoscope,  it  may  be 


Fig.  64. — Electric  head-light. 

withdrawn  gradually,  and,  as  it  comes  out,  the  whole 
mucous  surface  may  generally  be  well  inspected.  The 
normal  color  of  the  rectal  mucosa  is  a  light  pink  by  sun- 
light, and  appears  somewhat  more  accentuated  in  color  by 
electric  or  gas  light. 

In  acute  catarrhal  proctitis  the  membrane  appears  bright 
red  in  color  in  the  early  stage,  at  which  time  it  is  also 
swollen;  but  it  soon  becomes  darker,  secreting  at  the  same 
time  a  thick,  sticky  mucus,  which,  when  disturbed,  appears 
like  a  part  of  the  real  membrane. 

In  hypertrophic  catarrhal  proctitis  and  sigmoiditis  the 
mucous  membrane  is  pale,  edematous,  and  bulges  into  the 
opening  of  the  instrument,  unless  the  bowel  is  inflated. 
This  pale  membrane  can  also  be  observed  lying  in  con- 
centric folds  ahead  of  the  instrument,  lessening  to  a 
marked  extent  the  lumen  of  the  gut.  Mucus  accumulates 
16 


242 


LOCAL   TREATMENT   OF   THE   INTESTINES 


over  the  diseased  area,  appearing  as  a  sticky  coat,  whitish 
in  color  and  granular  in  form. 

In  the  atrophic  form  of  proctitis  the  mucous  membrane 
is  red  and  smooth,  the  mucous  folds  are  contracted,  the 
surface  is  somewhat  dry,  and  shows  a  tendency  to  adhere 
to  the  instrument  or  finger,  unless  well  lubricated.     As  this 


^FiG.  65. — Tuttle's  operating  proctoscope,  electrically'lighted 


condition  interferes  with  the  free  passage  of  fecal  matter, 
small  specks  and  particles  may  be  seen  about  on  the  rectal 
mucosa.  Shallow  ulcers  and  erosions  may  also  be  observed, 
due  to  abrasions  caused  by  the  passage  of  hard  feces  or 
sharp  substances  contained  therein. 

In  ulcerative  colitis   the  mucous  surface   of  the  upper 


LOCAL   APPLIANCES  243 

rectum  and  sigmoid  is  congested,  granular,  dry  and  glis- 
tening. The  ulcers  may  be  seen,  and  are  generally  shallow, 
irregular  in  shape,  without  well-defined  edges,  a  deeper  red 
than  their  surroundings,  bleeding  freely  when  touched, 
while  the  patient  complains  bitterly  of  the  pain  brought 
about  by  passage  of  the  instrument. 

In  mucous  or  membranous  colitis  there  are  no  charac- 
teristic gross  changes  upon  the  mucous  surface.  There 
may  be  some  congestion  and  thickening,  and  even  some- 
times ulceration,  but  it  is  impracticable  to  diagnose  this 
disease  by  examination  alone. 

In  early  malignant  disease  the  thorough  examination  of 
the  lower  bowel  is  most  important,  as  early  recognition 
will  afford  the  patient  a  "day  of  grace"  in  which  operative 
interference  may  relieve  certain  conditions  which  would 
otherwise  terminate  fatally. 

LOCAL  APPLICATIONS 

These  may  consist  of  powders,  astringents,  sedative  solu- 
tions, caustic  solutions,  or  irrigations  in  which  are  placed 
various  medicaments. 

Among  the  powders  suitable  for  application  to  the  in- 
flamed or  irritated  rectal  mucosa  are  aristol,  acetanilid, 
europhen,  boric  acid,  bismuth,  powdered  corn  starch  or 
powdered  slippery-elm.  These  may  be  applied  to  the 
inflamed  parts  by  means  of  a  powder-blower. 

There  are  many  local  applications  in  liquid  form  which 
are  both  suitable  and  beneficial  in  pathologic  conditions  of 
the  lower  bowel. 

For  ulcerated  areas,  the  first,  and  probably  most  useful 
application  is  hydrogen  peroxid,  which  oxidizes  the  putrid 
matter,  leaving  the  floor  of  the  ulcer  surgically  clean. 
Other  of  the  potent  applications  are  pure  phenol,  a  20  per 
cent,  solution  of  silver  nitrate,  bichlorid  of  mercury  solution, 
2  grains  to  the  ounce,  nitric  acid,  30  drops  to  the  ounce, 
tincture  of  iodin,  and  a  25  per  cent,  solution  of  aromatic 


244  LOCAL   TREATMENT   OF   THE    INTESTINES 

sulphuric  acid.  Where  the  appHcation  can  be  sharply 
limited,  the  lunar  caustic  may  be  used  in  solid  form.  This 
leaves  a  white  coagulum  of  albumen,  promoting  the  healing 
process. 

These  powerful  agents  are  not  suitable  for  application  to 
extensive  areas,  not  so  much  from  the  danger  of  absorption, 
as  the  difficulty  in  limiting  their  escharotic  action.     Their 


Fig.  66. — Albright's  sinus  irrigator;  hard-rubber. 

unwise  application  may  result  in  the  formation  of  un- 
desirable scar  tissue,  and  obstructive  constrictions  later 
on. 

Irrigations. — Direct  irrigation  of  the  duodenum  has  been 
employed  by  Gross  with  his  duodenal  tube.  He  first 
introduces  the  liquid,  then  siphons  it  out.  This  method 
has  not  come  into  general  use. 

Dr.  Ernest  Jutte  has  succeeded  fairly  well  in  his  efforts 
toward  transduodenal  lavage,  and  his  technic  will  be 
described,  as  set  forth  in  his  article  in  the  Journal  of  the 
American  Medical  Association,  Feb.  22,  1913. 

Transduodenal  lavage,  according  to  Dr.  Jutte,  is  to  the 
small  intestine  what  an  enema  is  to  the  large,  the  aim  bein:g 
to  bridge  the  stomach,  so  that  the  irrigating  fluid  does  not 
escape  into  that  viscus,  but  enters  directly  into  the  bowel. 

The  outfit  required  consists  of  i /16-inch  thin  rubber 
duodenal  tube,  with  perforations  near,  and  an  olive  at  the 
end,  an  aspirating  bottle,  a  suction  pump  or  an  ordinary 
syringe,  an  irrigator  and  rubber  connections,  and,  if 
swallowing  the  tube  is  difficult,  a  thin  wire  or  urethral 
catheter,  which  fits  into  the  hollow  stem  of  the  olive  to 
serve  as  an  introducer.  The  last-named  auxiliary  I  have 
never  found  necessary. 

The  patient  with  his  stomach  empty,  swallows  the  tube, 
lies  down  on  his  right  side  on  a  table,  and  drinks  a  tumblerful 
of  water.     In  this  position  gravity  brings  the  olive  near  the 


DUODENAL    LAVAGE 


245 


pylorus,  and  peristalsis  soon  pushes  it  through  along  with 
the  water.  Marked  stenosis  of  the  pyloric  outlet  of  the 
stomach  of  course  renders  the  passage  difficult  or  impossible. 
When  the  tube  has  been  in  a  sufficient  length  of  time,  some 
of  the  secretion  is  aspirated,  and,  if  alkaline,  it  may  be 
assumed  that  the  tube  is  in  the  duodenum.  (A  possible 
exception  is  the  presence  of  achylia  gastrica.) 

In  deciding  this  question  the  litmus-paper  test  has  been 
found  unreliable,  for  regurgitation  of  duodenal  contents 
into  the  stomach  may  give  a  bluish  tint  to  the  paper;  on 
the  other  hand,  the  duodenum  may  have  been  reached,  and 


Fig.  67. — Gross  duodenal  tube. 


the  red  paper  not  have  turned  blue,  because  an  acid  reaction 
in  the  first  portion  or  the  duodenum  is  not  infrequent. 
Fortunately  the  physical  appearance  of  the  aspirated  fluid 
is  generally  sufficient  to  remove  doubt.  A  slight  stringiness 
or  tenaciousness  indicates  its  intestinal  origin,  except  in 
cases  of  marked  gastric  catarrh. 

When  the  operator  is  satisfied  that  the  olive  is  in  the  right 
place,  lavage  may  be  begun.  The  duodenal  tube  is  dis- 
connected from  the  rest  of  the  apparatus,  and  attached  to  an 
ordinary  irrigator  or  rubber  bag  containing  about  2000  c.c. 


246  LOCAL   TREATMENT    OF   THE   INTESTINES 

of  irrigating  fluid.  The  patient  turns  on  his  back,  and 
from  1000  to  1250  c.c.  are  allowed  to  trickle  into  the  bowel. 
About  ten  minutes'  time  is  enough  for  this  quantity  to  run 
in  and  to  allow  peristalsis  to  gradually  push  it  onward,  so 
that  there  will  be  no  undue  distention  of  the  duodenum. 
To  make  certain  of  this,  the  flow  can  be  interrupted  once  or 
twice  by  a  few  minutes'  wait.  Light  abdominal  massage 
or  gentle  vibration  will  stimulate  peristalsis,  if  sluggish. 
After  enough  fluid  has  run  in — 1000  c.c.  are  easily  born — - 
the  tube  is  slowly  withdrawn,  and  the  patient  allowed  to 
rest  a  while. 

The  case  will  determine  the  nature  of  the  irrigating 
fluid.  In  nervous  disorders,  general  malaise,  anemia,  rheu- 
matism, indicanuria,  or  any  condition  where  it  is  desired 
to  thoroughly  clean  out  the  bowels.  Dr.  Jutte  uses  a  normal 
saline  solution,  9  grm.  to  1000  c.c,  at  body  temperature. 
To  flush  out  the  kidneys,  plain  distilled  water  causes  a 
copious  diuresis.  In  icterus  and  when  fat  digestion  is 
impaired,  the  addition  of  7  or  8  grains  of  pure  castile  soap 
(0.5)  to  1000  c.c.  of  saline  solution  is  beneficial.  Oc- 
casionally the  use  of  soap  is  followed  by  slight  nausea  or 
headache.  To  withdraw  fluid  from  the  body,  a  stronger 
solution  than  normal  saline  will  be  found  efficient.  It  is 
thought  that  astringents  added  to  the  saline  might  be 
helpful  in  catarrhal  enteritis,  and  quinine  in  amebic  dysen- 
tery.    This,  however,  has  not  been  proved  by  experience. 

Per sp"' ration,  temperature,  pulse  and  tension  remain 
practically  unchanged  during  this  irrigation,  though  an 
increase  of  the  fluid  temperature  above  that  of  the  body  will 
cause  a  corresponding  increase  in  pulse  and  tension. 
This  might  be  of  advantage  in  some  conditions,  but  should 
be  avoided  in  chronic  nephritis  and  similar  ailments.  This 
lavage  is  contraindicated  in  aortic  aneurysm  and  un- 
compensated heart  lesions.  It  seldom  causes  any  discom- 
fort, but  is  generally  followed  by  a  feeling  of  buoyancy  and 
well-being,  probably  due  to  flushing  out  the  intestinal 
toxins. 


ENEMAS  247 

Enemas. — The  various  methods  of  injecting  fluid  into 
the  bowel  come  under  this  term,  though  there  are  many 
variations  in  method  and  indication. 

The  principal  methods  consist  of: 

1.  The  simple  enema,  where  fluid  is  injected  into  the 
lower  bowel. 

2.  Irrigation  with  a  single  tube. 

3.  Irrigation  with  a  double-current  tube  or  other 
special  appliance. 

4.  Proctoclysis  by  the  drop  method  of  injection. 

There  are  quite  a  number  of  indications  for  the  em- 
ployment of  enemas,  or  intestinal  irrigation,  some  of 
which   are : 

For  local  treatment  of  diseased  conditions  of  the  gut,  as 
catarrhal  colitis. 

In  proctitis,  prostatitis,  or  any  acute  inflammation  in  the 
pelvic  region. 

For  the  relief  of  pain  and  irritability  in  the  anal  region, 
as  in  spasm  of  the  sphincter. 

To  aid  in  the  absorption  of  inflammatory  products  in  the 
pelvis,  as  of  post-uterine  adhesions. 

To  replace  the  loss  of  fluid  in  the  body,  as  in  cholera,  or 
after  severe  hemorrhages. 

To  dilute  the  poison  of  disease  and  promote  diuresis,  as 
in  uremia. 

To  check  hemorrhage  by  the  local  effect  of  fluid  either 
very  cold  or  very  hot,  as  in  hemorrhage  from  ulcers  in  the 
rectum. 

To  assist  in  emptying  the  bowel,  either  by  direct  irriga- 
tion, or  by  the  presence  of  the  fluid,  to  stimulate  the  gut  to 
expulsive  efforts,  as  in  constipation,  or  obstipation  from 
retained  masses  of  hardened  feces. 

To  affect  the  heat  centers,  as  by  hot  irrigations  in 
lowered  temperature  from  shock,  or  cold  irrigations  in  high 
fever. 

To  exert  an  antispasmodic  effect,  as  in  colic. 

To  aid  in  the  expulsion  of  gas,  as  in  excessive  tympanites. 


248  LOCAL   TREATMENT    OF    THE   INTESTINES 

To  exert  a  mechanical  effect,  as  in  intussusception. 

To  employ  the  fluid  as  a  vehicle  for  the  introduction  of 
nourishment,  as  in  nutritive  enemata. 

There  are  few  simple  mechanical  procedures  in  the  realm 
of  therapeutics  that  admit  of  the  display  of  more  tact, 
ingenuity  and  skill  than  in  the  administration  of  enemas. 
To  inject  into  the  bowel  a  sufficiency  of  fluid  to  meet  a 
given  indication,  without  pain  or  discomfort  to  the  patient, 
so  that  it  can  be  retained  long  enough  to  accomplish  the 
desired  purpose,  is  not  such  an  easy  matter  as  some  would 
suppose. 

The  necessary  apparatus  for  enemas  may  consist  of  a  i  to 
4-quart  fountain  syringe  of  rubber,  or  an  irrigating  jar  of 
glass  or  porcelain  with  an  opening  at  the  bottom.  This  is 
connected  with  rubber  tubing  which  may  have  at  its  end 
nozzles  of  various  sizes  and  shapes,  or  the  part  intended  to 
be  introduced  into  the  bowel  may  consist  of  a  colon  tube,  a 
tube  with  recurrent  flow,  or  a  soft -rubber  catheter. 

Either  hard-rubber  nozzles  or  soft-rubber  tubes  are 
preferable,  as,  in  the  injection  of  hot  fluids,  a  metal  nozzle 
becomes  unduly  heated  and  uncomfortable  to  the  patient. 

The  amount  of  hydrostatic  pressure  to  be  exerted  requires 
judgment.  In  irritable  conditions  of  the  intestinal  mucosa, 
the  flow  should  be  slow  and  gentle,  perhaps  frequently 
interrupted,  so  that  the  sensitive  bowel  will  not  spas- 
modically contract,  and  expel  the  fluid  too  soon.  Under 
such  conditions,  the  container  need  be  only  i  or  2  feet 
above  the  buttocks  of  the  patient.  Ordinarily  the  bag  or 
container  may  be  held  or  hung  from  2  to  5  feet  above  the 
patient.  Higher  than  that,  unless  extreme  hydrostatic 
pressure  is  desired,  as  in  intussusception,  is  fraught  with 
danger.  I  might  state,  however,  that  Dr.  A.  B.  Jamison, 
who  has  had  much  experience  in  intestinal  irrigation,  per- 
mits in  many  of  his  patients  the  water  to  enter  at  "hydrant 
pressure,"  claiming  that  in  no  instance  has  harm  been 
inflicted.  Individually,  I  would  hesitate  to  recommend 
such  force. 


ENEMAS 


249 


Quantity. — The  amount  of  fluid  to  be  injected  depends 
upon  the  results  desired.  To  simply  stimulate  lagging 
peristalsis,  a  pint,  or  even  less,  is  usually  sufficient.  Many 
individuals  are  slightly  inclined  toward  constipation,  and 
need  only  a  gentle  stimulus  to  "wake,"  as  it  were,  intestinal 
contractions.  Many  of  these  have  in  the  toilet  a  convenient 
fountain  syringe,  which  is  brought  into  use,  should  the 
regular  daily  evacuation  be  tardy.  The  employment  of  a 
small  enema  of  warm  water  under  such  circumstances 
causes  practically  no  disturbance  of  the  alimentary  tract, 
and  is  greatly  preferable  to  the  constant  and  promiscuous 
self-administration  of  laxatives. 

Enemas  intended  to  flush  the  colon,  or  to  dislodge  fecal 
accumulations  higher  up,  may  consist  of  a  quart  and  a  half, 
or  even  two  quarts.  The  last  I  consider  a  maximum.  The 
practice  of  introducing  into  the  bowel  vast  quantities  of 
water — i  or  2  gallons,  or  even  more,  is  reprehensible,  and 
liable  to  cause  dilatation,  with  later  on  paralysis  of  the 
bowels. 

A  number  of  years  ago  a  well-meaning  but  ill-informed 
individual  promulgated  a  theory  that,  by  frequently 
flushing  the  colon  with  enormous  quantities  of  warm  water, 
many  of  the  ills  of  life  might  be  mitigated  or  cured.  This 
fad,  like  many  others  containing  some  elements  of  truth, 
became  quite  popular  for  a  season,  to  the  great  harm  of 
some  of  its  devotees.  As  a  sad  commentary,  it  is  reported 
that  the  originator  himself  died  from  the  effects  of  dilated 
and  atonic  bowels. 

Let  me  insist  that  several  enemas  of  i  quart  each  are 
infinitely  better  than  one  enema  of  several  quarts.  If  this 
book  convinces  its  readers  of  this  one  basic  fact,  my  efforts 
will  be  well  repaid. 

Many  times,  if  the  first  enema  is  fruitless,  the  water 

■  returning  clear,  if  repeated  one  or  more  times,  peristalsis 

will  be  set  up,  the  hardened  contents  will  in  the  meanwhile 

be  softened,  and  satisfactory  fecal  results  will  ensue.     The 

mere  fact  of  repeated  injections  need  cause  no  more  appre- 


250  LOCAL   TREATMENT    OF   THE   INTESTINES 

hension  than  the  mere  fact  of  repeated  ablutions  to  the  sur- 
face of  a  soiled  and  crusted  skin. 

Temperature. — Cold  enemas  are  indicated  only  in  the 
presence  of  hemorrhage  or  hyperpyrexia.  Their  use  is 
limited,  and  generally,  any  benefit  which  might  be  attained 
by  the  injection  of  cold  fluid  into  the  bowel,  is  more 
comfortably  and  safely  accomplished  by  other  means. 

Generally  speaking,  the  fluid  should  be  about  the  body 
temperature — perhaps  a  little  warmer.  For  the  relief  of 
inflammation  in  the  intestinal  mucosa  or  adjacent  struc- 
tures, the  water  may  be  quite  hot.  Albright  advocates  a 
temperature  of  120°  F.,  while  Jamison  advises  a  tem- 
perature of  135  or  even  140°  F.  I  would  hardly  advise  an 
irrigation  with  a  temperature  above  125°  F. 

The  irrigating  tube  must  never  be  removed  while  the  hot 
solution  is  in  the  rectum,  as,  should  it  come  in  contact  with 
the  anus,  it  would  cause  decided  pain.  It  must  be  re- 
membered that  the  interior  of  the  rectum  will  comfortably 
bear  a  degree  of  heat  that  the  anus  cannot  endure,  so  the 
instrument  should  not  be  withdrawn  until  after  the  fluid 
ceases  flowing  through  it,  and  then  slowly. 

Lubrication. — It  is  always  conducive  to  the  comfort  of 
the  patient  that  the  nozzle,  the  entering  tube,  or  the  colon 
tube  be  well  lubricated.  Vaseline,  olive  oil,  castor  oil 
(warmed),  or  even  toilet  soap  will  answer  the  purpose. 
Laundry  soap,  or  the  cheap  grades  of  turpentine  soap 
are  useful  in  the  water,  but  are  unsuitable  to  lubricate  a 
tube  that  passes  over  a  possibly  tender  or  excoriated 
surface. 

Preparation  of  the  Irrigating  Fluid. — A  simple  enema  for 
gentle  stimulation  of  peristalsis  may  consist  of  warm  water 
alone. 

The  so-called  S.  S.  enema  consists  of  warm  water  into 
which  sufficient  soap  is  rubbed  to  form  a  liberal  amount  of 
soapsuds.  In  such  an  enema  laundry — or  turpentine — 
soap  may  be  used,  as  this  soap  exerts  a  slightly  stimuJating 
effect. 


ENEMAS  251 

The  saline  enema  (normal)  consists  of  one  teaspoonful  of 
common  table  salt  to  the  pint  of  water. 

An  oxgall  enema  contains  one  teaspoonful  of  oxgall  to  the 
pint  of  water. 

The  Hare  enema  consists  of  magnesia  sulphate,  one 
tablespoonful,  glycerin,  i  ounce,  water,  2  quarts. 

Various  carminative  enemas  may  be  prepared  by  adding 
to  the  water  one  or  more  tablespoonfuls  of  milk  of  asaf etida, 
to  the  quart  of  water,  one  teaspoonful  of  powdered  alum 
or  powdered  borax  to  the  quart,  or  a  weak  infusion  of 
camomile. 

Emollient  enemas  contain  corn  starch  in  sufficient 
quantity  to  thicken  the  fluid;  or  flaxseed  meal  or  slippery 
elm  bark,  with  the  water  strained.  Gum  arable  or  traga- 
canth  is  also  used. 

Antiseptic  enemas  may  contain  permanganate  of  potash, 
one  to  two  or  five  thousand,  nitrate  of  silver,  1 5  grains  to  the 
quart,  phenol,  30  grains  to  the  quart  (being  sure  that  it  is 
all  returned),  chlorinated  lime,  half  teaspoonful  to  the 
quart,  commercial  sulphuric  acid,  1/2  dram  to  the  quart,  or 
the  liquor  alkaline  antiseptic  (N.  F.)  i  or  2  ounces  to  the 
quart.. 

For  softening  and  healing  enemas  there  may  be  em- 
ployed several  of  the  oils.  These  are  also  employed  in  the 
treatment  of  constipation,  and,  when  rightly  used,  are 
successful  in  a  large  per  centage  of  cases.  For  healing  an 
irritated  intestinal  mucosa,  there  may  be  added  to  the  oil 
a  small  amount  of  phenol,  i  dram  to  the  pint,  tincture  of 
iodin,  the  same  amount,  or  bismuth  subnitrate  in  any 
quantity  desired,  so  the  oil  is  not  made  too  thick  by  its 
addition.  For  inflammatory  conditions,  when  pain  or 
tenesmus  is  present,  and  the  oil  is  not  expected  to  remain 
in  the  bowel  any  great  length  of  time,  the  amount  injected 
may  vary  from  8  ounces  to  a  quart,  or  even  more. 

In  constipation,  the  method  is  different.  The  oil  should 
be  placed  in  a  glass  or  hard-rubber  irrigating  jar,  as  its 
frequent  use  rots  the  bag  of  a  fountain  syringe.     Not  over 


252  LOCAL   TREATMENT    OF    THE    INTESTINES 

3  ounces  should  be  injected  the  first  time,  though,  as  the 
patient  finds  the  bowel  will  retain  more,  this  amount  may  be 
increased  up  to  8  ounces.  When  injecting  the  oil,  the  bed 
should  be  protected  by  a  rubber  sheet  or  other  covering. 
The  patient  should  lie  on  his  left  side  with  his  legs  flexed  and 
his  hips  slightly  elevated.  The  rectal  tube  is  slowly 
introduced,  and,  as  the  oil  flows  in,  is  gently  pushed  up 
until  it  enters  as  much  as  8  or  10  inches.  After  the  oil 
flows  in  the  tube  is  withdrawn,  and  compressed  by  the 
finger  during  its  exit  to  prevent  the  escape  of  random  dx-ops. 
The  patient  should  remain  on  his  left  side  for  twenty  or 
thirty  minutes,  and,  if  possible,  the  oil  should  remain  in  all 
night.  This  usually  is  accomplished,  except  in  rare  in- 
stances of  extreme  irritability  of  the  rectum,  or  where  the 
anus  is  patulous,  allowing  it  to  escape  during  sleep.  This 
injection  of  oil  is  generally  followed  by  a  satisfactory  evacua- 
tion of  the  bowels  the  following  morning;  but,  if  not,  a 
small  S.  S.  enema,  or  a  glycerin  suppository,  will  set  up 
enough  intestinal  contractions. 

This  method  is  specially  applicable  to  those  forms  of 
constipation  characterized  by  hard  and  dry  fecal  masses, 
with  a  tendency  to  accumulation  of  scybalous  collections 
high  up  in  the  large  intestine. 

The  Kind  of  Oil  to  be  Used. — Some  writers  advise  the 
pure  olive  oil,  which  is  both  expensive  and  hard  to  obtain 
in  many  instances.  Hemmeter  has  observed  occasional 
irritation  from  fatty  acids  in  the  oil,  and  advises  shaking 
the  oil  with  hot  water,  as  the  latter  takes  up  the  fatty  acid. 
Rosenheim  adds  a  little  bicarbonate  of  soda  to  neutralize 
the  acid.  Either  of  these  procedures  I  have  never  found 
necessary  or  expedient.  Linseed  oil  has  been  advocated 
by  some,  but  when  warm  it  is  so  fluid,  that  it  tends  to  run 
out  of  the  bowel,  unless  the  sphincters  are  quite  efficient. 

The  best  and  most  satisfactory  oil  in  my  experience  is  the 
cottonseed  oil,  especially  after  it  has  been  refined  for  cooking 
purposes.  The  various  cooking  oils  are  cheap,  easily  ob- 
tained  at   the   nearest   grocery   store,    and   answer   every 


IRRIGATION   or   LARGE   INTESTINES  253 

purpose  that  can  be  attained  by  pure  and  expensive  olive 
oil. 

When  it  is  considered  that  most  of  the  so-called  olive  oil 
now  on  the  market  is  adulterated  with  cotten-seed  oil,  the 
reader  may  see  that  it  is  unnecessary  to  have  the  patient 
pay  a  large  price  for  supposed  olive  oil,  when  the  pure 
cotton-seed  oil  is  fully  as  suitable  for  the  desired  purpose, 
and  much  cheaper. 

The  Colon  Tube. — When  it  is  desired  to  carry  the  in- 
jected fluid  high  up  in  the  bowel,  a  colon  tube  may  be  em- 
ployed. This  may  be  of  hard  rubber,  about  i8,  English 
size,  and  fairly  stiff.  A  tube  that  is  unduly  flexible  is 
worse  than  useless.  Colon  tubes  are  also  furnished  in 
metal,  made  in  sections,  but  these  are  not  satisfactory. 
There  are  few  appliances  more  deceptive  than  this,  and, 
unless  the  operator  is  careful,  the  tube  will  bend  upon  itself 
in  the  ampulla  of  the  rectum.  The  proper  method  of 
introducing  a  colon  tube  is  to  press  it  upward  gently  as  the 
water  flows,  allowing  in  the  meanwhile  rather  more  hy- 
drostatic pressure  than  is  exerted  in  a  simple  enema.  The 
flow  may  be  interrupted  whenever  there  is  discomfort  or 
tendency  to  expel  the  fluid,  so  as  to  allow  the  bowel  to 
adjust  itself  to  its  contents.  The  operator  will  have  to 
judge  by  both  the  sense  of  touch  and  the  freedom  of  flow  of 
the  fluid  as  to  whether  or  not  the  tube  is  really  high  up  in 
the  bowel. 

Irrigation  of  the  Large  Intestine. — This  is  accomplished 
by  several  methods.  To  irrigate  with  a  single  tube,  a 
colon  tube  or  even  a  hard-rubber  nozzle  may  be  attached 
to  a  rubber  tube  about  2  feet  long,  which  is  surmounted  by  a 
funnel.  The  water  is  poured  in  the  funnel,  sent  into  the 
bowel  from  an  elevation  of  about  2  feet,  and  siphoned  out 
by  suddenly  lowering  the  funnel,  as  in  gastric  lavage.  This 
method  is  not  very  satisfactory,  and  is  useful  only  to  re- 
move softened  feces  or  small  shreads  of  mucus,  or  in  the 
absence  of  better  appliances. 

The  best  and  most  scientific  methods  of  irrigation  lie  in 


254 


LOCAL   TREATMENT    OF   THE    INTESTINES 


the  several  forms  of  recurrent  tubes,  in  which  the  water 
flows  out  as  fast  as  it  enters,  there  is  no  straining  or  tenes- 
mus, and  the  temperature  of  the  fluid  can  be  absolutely 
regulated.  By  this  method  also  an  unlimited  quantity  of 
the  irrigating  fluid  may  be  made  to  lave  the  intestines, 
and  besides  mechanically  cleaning  them,  the  flatus  is  re- 
lieved by  the  suction  of  the  return  flow. 

I  prefer  the  Kemp  flexible  recurrent  irrigator  and  the 
Albright  small  hard-rubber  irrigator,  though  Tuttle,  Hem- 
meter  and  several  others  have  devised  successful  in- 
struments for  this  purpose. 


Fig.  68. — Jamison's  irrigator. 


The  principle  is  simple,  being  a  double,  rigid  tube,  where 
the  fluid  enters  by  a  central  tube,  while  the  outflow  is  car- 
ried off  by  the  outer  tube  into  which  the  fluid  flows  by 
lateral  oriflces.     The  illustration  will  make  this  plain. 

Dr.  A.  B.  Jamison  has  contrived  an  ingenious  irrigating 
outfit,  which  he  calls  the  "Niagara  Fountain  Syringe." 
This  is  taken  by  the  patient  in  the  sitting  position,  and 


IRRIGATION   OF   THE    LARGE   INTESTINE  255 

when  the  bowel  is  full,  a  simple  half -turn  of  a  hard-rubber 
tube  opens  a  valve,  and  releases  the  water.  The  illustra- 
tion will  make  the  principle  clear. 

In  using  the  double-current  irrigating  tube,  the  patient 
may  be  either  on  the  back  or  side,  just  so  the  hips  are 
elevated.  The  height  of  the  douche  bag  or  irrigating  jar 
should  be  from  3  to  5  feet  above  the  patient.  There  are 
several  precautions  advisable,  which  will  facilitate  every 
step  of  the  irrigation :  Allow  the  fluid  to  flow  from  the  tube 
before  insertion,  so  as  to  force  out  the  air,  and  then  check 
the  flow,  then  renew  the  flow  as  the  tip  of  the  instrument 
passes  well  through  the  spincters,  so  as  to  force  the  mucosa 
away  from  the  irrigator  and  lateral  fenestrse. 

The  instrument  should  be  well  lubricated  (the  flowing 
fluid  will  warm  it) ,  inserted  with  a  gentle  rotary  movement 
with  the  tip  directed  slightly  back  toward  the  sacrum. 
Do  not  use  force  in  entering,  nor  press  the  tip  of  the  tube 
against  the  intestinal  walls.  Should  the  flow  cease,  rotate 
the  tube  slightly,  or  withdraw  it  some  while  rotating,  and 
then  push  it  gently  backward  and  forward  till  the  flow 
resumes.  Occasionally,  where  there  are  much  hardened 
fecal  contents  present  in  the  bowel,  the  larger  masses  need 
to  be  cleared  with  a  soapsuds  enema,  after  previously 
softening  them  with  oil  or  glycerin.  The  irrigator  should 
be  introduced  to  one-half  its  length  in  prostatic  cases,  and 
full  length  for  high  irrigation. 

Should  the  tube  encounter  an  obstruction,  a  rectal 
examination  will  disclose  the  cause,  such  as  a  possible 
enlarged  prostate,  uterine  fibroids,  redundant  hemorrhoids, 
etc.  These,  however,  can  generally  be  passed  with  the 
tube,  after  their  location  and  size  are  known.  When  with- 
drawing, bring  out  the  tube  with  a  gentle  rotary  pull,  lest 
the  mucosa  catch  in  the  fenestrae. 

When  it  is  desired  to  thoroughly  irrigate  the  whole  colon, 
the  irrigation  may  be  started  with  the  patient  on  the  left 
side  with  his  hips  elevated ;  as  the  irrigation  proceeds,  he  is 
gently  rotated  to  the  dorsal  position,  then  to  his  right  side. 


256  LOCAL   TREATMENT    OF    THE   INTESTINES 

As  the  irrigation  is  still  kept  up,  he  may  be  rotated  in  the 
opposite  direction,  and  the  procedure  concluded  after  he 
is  returned  to  the  left  side.  It  is  also  of  assistance  to 
raise  the  shoulders  while  on  the  right  side,  as  this  tends  to 
make  the  fluid  gravitate  into  the  caput  coli. 

Temperature  of  the  Irrigating  Fluid. — This  may  vary 
from  100°  F.  to  105°  F.  in  intestinal  catarrh  to  110°  F.  in 
typhoid  fever  or  any  toxic  condition,  as  this  higher  tem- 
perature increases  its  eliminative  effect.  Jamison  uses 
irrigations  as  hot  as  125  to  135°  F. 

Solutions  Employed. — Thin  flaxseed  tea,  normal  saline 
solution  with  spirits  of  peppermint  or  cinnamon  or  fennel, 
plain  water  with  milk  of  asafetida,  soda,  boric  acid,  tannic 
acid,  tannin,  or  alum,  the  latter  six  medicaments  being  used 
in  strength  of  i  dram  to  the  quart.  Others  are  the  solutions 
of  /  silver  nitrate,  potassium  permanganate  and  alkaline 
antiseptic  liquid,  as  previously  mentioned. 

One  more  irrigating  fluid  I  wish  to  specially  mention  as 
worthy  of  use — the  plain  kerosene  or  coal  oil  of  commerce. 
Its  amebacide  effect  will  be  considered  later,  but  as  an 
irrigating  fluid  in  chronic  proctitis  and  colitis,  where  there 
are  old  and  unhealthy  ulcers,  with  superficial  sloughs,  and 
perhaps  a  chronic  diarrhea,  an  irrigation  of  one  quart  on 
alternate  days,  until  about  three  or  four  irrigations  have 
been  given,  will  in  most  cases  yield  gratifying  results.  There 
seems  to  be  no  danger  of  toxic  effects,  for  in  several  in- 
stances quite  a  residue  of  the  oil  has  been  retained  one 
to  three  hours  before  escaping,  and  in  no  instance  have 
any  evil  or  disquieting  symptoms  ensued.  I  commend  this 
unhesitatingly. 

Proctoclysis. — By  this  is  meant  the  injection  of  normal 
saline  or  other  solution  into  the  rectum  by  the  drop  method, 
as  first  suggested  by  Dr.  J.  B.  Murphy,  of  Chicago.  This 
procedure  is  of  special  value  in  sepsis,  and  is  of  use  as  an 
adjunct  to  other  treatment  in  post-operative  shock,  in- 
testinal dilatation  and  atony,  and  uremia.  In  septic 
conditions,  it  is  well,  however,  to  first  thoroughly  irrigate 


PROCTOCLYSIS  257 

the  colon  with  a  saHne  solution  at  120°  F.,  then  follow 
with  proctoclysis. 

One  of  the  main  difficulties  in  the  administration  of  a 
solution  by  the  drop  method,  is  the  maintenance  of  a 
constant  temperature.  There  have  been  several  methods 
suggested,  but  probably  the  most  simple  and  satisfactor)- 
is  the  employment  of  a  vacuum  bottle,  as  directed  by 
Kemp. 

His  method  is  as  follows:  Through  a  screw  cap,  which 
closes  the  bottle,  passes  a  small  hard-rubber  connecting 
tube,  to  which  is  attached  the  outflow  tube.  Parallel 
with  this  is  the  filiform  tube,  which  allows  the  entrance 
of  a  fine  column  of  air,  so  as  to  render  the  flow  possible. 
This  last  tube  passes  through  the  solution  to  within  about 
one  eighth  of  an  inch  from  the  bottom  of  the  bottle.  As 
the  instrument  is  inverted  when  in  use,  it  would  correspond 
to  the  same  distance  from  the  top  of  the  bottle.  This 
filiform  tube  is  of  hard  rubber  externally  where  exposed 
to  the  air,  as  a  non-conductor  of  heat.  The  part  lying 
within  the  bottle  is  purposely  made  of  metal,  so  that  it  is 
rapidly  heated  from  the  surrounding  solution,  and  the 
entering  air  is  thus  also  heated. 

A  series  of  experiments  have  demonstrated  that  there  is  a 
loss  of  only  i  or  2°  F.  in  the  temperature  of  the  solution 
in  the  bottle  during  the  administration  of  proctoclysis 
lasting  half  an  hour  to  an  hour.  The  screw  compression 
valve  is  applied  close  to  the  bottle  attachment,  so  as  to 
avoid  as  much  as  possible  the  solution  cooling  in  the  soft 
outflow  tube.  This  outflow  tube  is  joined  to  the  catheter 
by  a  short  piece  of  glass  tubing  for  the  purpose  of  observ- 
ing whether  the  flow  is  constant.  The  catheter  for  rectal 
injection  passes  through  a  self -retaining  rectal  tip,  and  this 
catheter  and  tip  can  be  inserted  any  length  desired.  The 
conducting  tube  is  quite  thick.  An  asbestos  tube  sur- 
rounds the  conducting  tube  from  its  junction  at  the  bottle 
to  the  catheter.  This  lessens  the  dissipation  of  heat,  and 
is  greatly  preferable  to  the  use  of  cumbersome  hot  towels. 
17 


258  LOCAL   TREATMENT   OF   THE   INTESTINES 

The  asbestos  wrapping  can  be  occasionally  slipped  off  the 
glass  connecting  joint,  so  as  to  observe  the  flow.  The 
vacuum  bottle  is  filled  in  the  usual  manner,  and  the  special 
cap  with  attachment  screwed  on.  The  bottle  is  then  in- 
verted, and  suspended  by  a  sling.  A  small  amount  of 
fluid  will  escape  from  the  bottle  by  the  filiform  air  tube 
until  the  solution  reaches  the  level  of  the  tube,  which  is 
now  near  the  top  of  the  bottle.  The  bottle  is  now 
suspended  about  6  inches  above  the  rectum,  or  higher,  if 
desired,  and  the  flow  tested  for  proper  speed  before  insert- 
ing the  rectal  tip  or  catheter.  If  flatus  occur,  lower  the 
reservoir  for  a  short  time  to  below  the  level  of  the  ab- 
domen, so  the  gas  may  escape  into  the  bottle.  Should 
this  not  be  adequate  for  the  escape  of  the  flatus,  it  may 
be  necessary  to  remove  the  tube  for  a  short  period. 

At  the  start  the  speed  of  the  drop  is  more  rapid,  and 
though  gauged  to,  say,  fifteen  drops  per  minute,  may,  in  the 
course  of  two  minutes  drop  to  five.  A  test  of  two  to  three 
minutes  should  be  made,  therefore,  before  inserting  the 
catheter,  so  as  to  insure  a  constant  flow  at  the  desired  rate. 
Other  special  apparatus  for  the  maintenance  of  heat 
consists  of  gas  or  oil  burners  under  the  container,  or  electric 
heaters. 

Needle  Douche;  Nebulizer;  Colonic  Massage  Bags. — 
These  instruments  have  been  devised  by  Dr.  Fenton  Turck, 
of  Chicago,  and  may  possess  some  value.  The  colon  needle 
douche  is  a  double-current  tube,  slender,  and  about  12 
inches  long,  with  the  inflow  tube  fitted  with  an  orifice 
through  which  the  fluid  escapes  in  a  fine,  needle-like  stream. 
The  nebulizer  is  an  ordinary  instrument  of  this  sort  at- 
tached to  a  rectal  or  colon  tube,  and  is  recommended  by  its 
inventor  for  spraying  oil  of  cloves  or  cinnamon  into  the 
colon  for  their  antiseptic  effect.  He  also  recommends 
distensible  bags  for  the  inflation  and  massage  of  the  rectum 
and  colon.  These  bags  are  of  doubtful  use,  and  I  would 
hesitate  to  advocate  them.  ' 

It  will  be  observed  from  the  various  methods  discussed 


LOCAL   TREATMENT    OF   THE   INTESTINES  259 

in  this  chapter  that  a  considerable  portion  of  therapeutics 
directed  toward  alleviation  of  gastrointestinal  ailments  may- 
be properly  placed  under  the  caption  of  "Local  Treatment 
of  the  Intestines."  Let  me,  therefore,  urge  my  readers  to 
not  underestimate  the  importance  of  thoughtful  con- 
sideration and  care  of  the  intestines,  especially  the  colon 
and  rectum,  for  in  many  instances  the  etiologic  key  lies 
here,  and  here  also,  by  the  exercise  of  suitable  measures, 
may  be  discovered  a  solution  of  the  whole  pathologic 
problem. 


CHAPTER  XI 

HYDROTHERAPY  IN  GASTROINTESTINAL 
DISEASES 

Water,  the  cup  that  cheers  but  not  inebriates,  the  uni- 
versal solvent,  has  claimed  attention  from  earliest  antiq- 
uity. As  a  therapeutic  agent  it  has  proved  most  effica- 
cious, and  since  Naaman,  the  Syrian,  was  healed  of  his 
leprosy  by  bathing  in  the  river  Jordan,  even  to  the  present 
moment,  there  has  been  no  lack  of  earnest  adherents  to  the 
various  methods  of  hydrotherapy. 

The  literature  on  the  subject  is  voluminous,  a  search  of 
the  list  of  references  in  the  Surgeon-General's  Library, 
Washington,  revealing  32  volumes  with  640  citations 
devoted  to  hydrotherapy  alone. 

The  students  and  investigators  of  the  Old  World  have 
been  most  industrious  in  the  elucidation  of  this  broad 
subject,  while  in  the  United  States  we  are  greatly  in- 
debted to  Dr.  Simon  Baruch,  of  New  York,  and  Dr.  J.  H. 
Kellogg,  of  Battle  Creek;  though  their  labors  have  been 
ably  augmented  by  a  host  of  other  earnest  workers. 

I  may  properly  say  that  there  is  no  phase  of  hydro- 
therapy more  important  than  its  application  to  gastro- 
intestinal diseases,  and  an  attempt  will  be  made  to  cover  the 
practical  indications  for  and  methods  of  its  employment. 

First  I  desire  to  discuss  the  much  misunderstood  subject 
of  drinking  water  with  meals,  for  with  a  few  exceptions, 
but  scant  attention  has  been  accorded  it  by  writers  on 
digestive  problems,  who  allude  to  it  in  a  careless  and 
perfunctory  manner. 

There  is  a  widespread  idea  (happily  being  now  somewhat 
abandoned)  that  the  habit  of  imbibing  water  or  any  other 

260 


DRINKING   WATER   WITH   MEALS  26 1 

fluid  as  food  is  being  taken  is  harmful  to  digestion ;  that  it 
dilutes  and  weakens  the  gastric  juices,  thereby  interfering 
with  the  satisfactory  functioning  of  the  stomach,  and  the 
orderly  progress  of  digestion.  This  idea  is  by  no  means 
confined  to  the  laity,  for  the  medical  profession  almost 
unanimously  advise  strongly  against  the  drinking  of  large 
amounts  of  water  at  meal  time,  and  as  a  matter  of  routine 
prohibit  the  practice.  I  have  now  at  hand  the  printed  diet 
list  of  a  prominent  stomach  specialist,  bearing  the  in- 
junction— "Do  not  take  more  than  one  and  one-half 
glasses  of  fluid  with  any  meal." 

This  wholesale  indictment  is  radically  wrong;  it  is  based 
on  erroneous  physiologic  conclusions,  and  perpetuated  by 
tradition.  As  a  shining  instance,  however,  of  one  who 
could  cast  aside  tradition,  and  utter  words  almost  pro- 
phetic, let  me  quote  the  late  Prof.  Austin  Flint,  who,  in 
a  lecture  delivered  twenty-eight  years  ago,  said,  "Gentle- 
men, theoretically,  the  ingestion  of  much  water  would  dilute 
the  gastric  juice,  and  impair  the  digestion,  but  practically 
this  does  not  seem  to  be  the  case." 

The  older  works  on  physiology  taught  that  the  contents  of 
the  stomach  were  kept  in  a  general  rotary  movement,  so  as 
to  become  more  uniformly  mixed;  that  each  portion  of  the 
stomach  contents  was  thoroughly  "churned,"  as  it  were,  so 
that  the  gastric  juice  would  quickly  and  effectively  per- 
meate the  whole  mass ;  that  the  salivary  digestion  of  starchy 
foods  ceased  as  soon  as  the  stomach  was  reached;  and  that 
the  rriusculature  of  the  stomach  had  a  decided  triturating 
power. 

In  recent  years  the  subject  has  been  investigated  with 
great  care  by  means  of  X-rays,  on  the  excised  stomach, 
and  by  means  of  tambours  introduced  into  that  viscus  to 
meaure  the  pressure  changes.  These  researches  all  unite 
in  emphasizing  one  fundamental  fact — mainly,  that  the 
fundic  end  of  the  stomach  is  not  actively  concerned  in  its 
movements,  but  serves  rather  as  a  reservoir  for  retaining 
the  bulk  of  the  food,  allowing  the  ptyalin  more  time  to 


262  HYDROTHERAPY   IN   GASTROINTESTINAL   DISEASES 

continue  its  work,  and  by  the  normal  tone  existing  in  the 
fundus,  as  well  as  in  the  whole  organ,  to  gently  force  its 
contents  down  into  the  main  body  and  pyloric  region  of  the 
stomach,  as  is  required  by  orderly  digestive  progress. 
Furthermore,  the  observations  of  Cannon,  Grutzner  and 
Pavlov  indicate  that  the  successive  portions  of  a  meal  as 
taken,  instead  of  being  speedily  mixed,  are  arranged  in 
definite  strata.  The  food  first  taken  lies  next  to  the  walls 
of  the  stomach,  while  the  succeeding  portions  are  arranged 
regularly  in  the  interior  in  a  concentric  fashion.  This  is 
readily  understood,  when  one  recalls  that  the  healthy 
stomach  has  never  any  empty  space  within;  its  cavity  is 
only  as  large  as  its  contents,  so  that  the  first  portion  of  the 
food  eaten  entirely  fills  it,  and  successive  portions,  finding 
the  wall  layer  occupied,  are  received  into  the  interior.  The 
ingestion  of  much  liquid  into  an  atonic  stomach  would, 
therefore,  interfere  somewhat  with  this  stratification,  but 
not  so  in  a  stomach  of  normal  tone. 

As  to  the  order  in  which  the  different  elements  are 
evacuated  from  the  stomach,  it  has  been  demonstrated  by 
Cannon  and  Pavlov  that,  when  liquid  food  alone  is  taken,  it 
can  be  forced  into  the  duodenum  in  a  few  minutes,  and  that 
when  a  mixed  meal  is  taken,  the  liquid  part  is  first  expelled, 
then  the  major  part  of  the  carbohydrates,  then  the  major 
part  of  the  proteins,  and  last  the  fats.  Fats  remain  long 
in  the  stomach  when  taken  alone,  and  when  combined  with 
other  food-stuffs  markedly  delay  their  exit  through  the 
pylorus.  On  account  of  the  stratification  of  the  food  as  it 
occupies  the  stomach,  that  taken  first  has  the  position  of 
advantage.  If  it  is  carbohydrate,  it  is  promptly  ejected 
into  the  intestine;  but  if  it  is  protein  or  fat,  the  passage  of 
the  carbohydrate  will  be  delayed.  Water,  though,  finds  a 
ready  exit  when  taken  at  any  stage  of  a  meal . 

There  are  a  few  conditions,  nevertheless,  in  which  much 
water  with  meals  is  contraindicated :  In  gastroptosis,  on 
account  of  the  weight  of  the  water,  which  drags  heavily 
on  the  already  relaxed  and  inefficient  gastric  supports;  in 


DRINKING   WATER   WITH   MEALS  263 

dilated  or  atonic  stomachs — those  where  splashing  sounds 
may  be  easily  elicited,  because  there  is  not  enough  tone  to 
the  musculature  to  promptly  evacuate  the  contents,  and  an 
excess  of  water  added  to  a  meal  would  promote  further 
atony  and  dilatation;  in  patients  with  weak  hearts  or 
uncompensated  valvular  lesions.  Occasionally,  where  there 
is^a  marked  tendency  to  colic,  or  spasm  of  the  pylorus, 
water  should  be  drunk  moderately  with  meals.  I  might 
mention  also  that  copious  draughts  of  ice-cold  water 
gulped  down  during  fatigue  or  profuse  perspiration  are 
both  unhygienic  and  dangerous. 

Gn  the  other  hand,  I  find  that  a  large  proportion  of 
patients  coming  under  my  notice,  who  suffer  from  poor 
nutrition,  constipation,  intestinal  toxemia,  and  numerous 
other  states  of  disordered  digestion,  are  those  who  drink  no 
water  with  meals,  or  if  at  all,  very  sparingly. 

Desiring  some  additional  data  on  this  interesting  but 
neglected  subject,  in  November,  1909,  I  enlisted  the  aid 
of  sixteen  young  men,  sophomore  students  at  the  Atlanta 
School  of  Medicine,  who  cheerfully  agreed  to  submit  for 
eight  days  to  a  series  of  experiments  along  this  line. 

These  young  men  were  of  healthy  physique,  and,  with 
one  exception,  reported  daily  evacuation  of  the  bowels. 
Their  ages  ranged  from  twenty  to  thirty-three,  their  weights 
from  124  to  168  pounds.  All  had  normal  hearts,  lungs  and 
kidneys,  and  their  stomachs  were  of  proper  size  and 
correct  position.  Each  one  was  in  the  habit  of  drinking 
one  or  two — not  more — glasses  of  water  or  other  fluid 
with  each  meal. 

Eight  of  the  young  men  were  instructed  to  drink  no  water 
or  other  fluid  with  meals,  and  between  meals  to  drink  no 
more  than  demanded  by  actual  thirst.  The  other  eight 
were  instructed  to  drink  four  glasses  or  i  quart  of  water 
with  each  meal,  and  between  meals  to  drink  it  or  not  as  was 
desired. 

These  young  men  were  carefully  watched,  regularly 
weighed,    and    each    symptom   recorded    as   it    appeared. 


264  HYDROTHERAPY   IN    GASTROINTESTINAL  DISEASES 

Omitting  the  detailed  reports,  I  summarize  the  results  as 
follows : 

Of  the  eight  who  drank  no  water,  all  lost  in  weight — from 
8  ounces  to  2  pounds — with  one  exception.  This  exception 
remained  at  exactly  the  same  weight,  and  it  might  be  men- 
tioned that  this  young  man  was  holding  a  position  as 
railway  mail  clerk  in  addition  to  his  college  work,  and  that 
he  was  so  accustomed  to  irregular  habits  that  cutting  off  his 
water  did  not  affect  him  like  the  others.  In  addition  to 
the  loss  in  weight,  each  one  complained  of  headache  and 
more  or  less  constipation.  Only  their  loyalty  made  them 
hold  out  to  the  end  of  the  term  of  days,  and  they  all  seemed 
glad  to  return  to  their  accustomed  allowance  of  water. 

The  eight  who  drank  four  glasses  at  each  meal  fared  much 
better.  One  of  them  said  that  four  glasses  rather  distended 
his  stomach,  but  did  not  cause  any  marked  discomfort. 
Of  these  eight,  all  gained  weight — from  4  ounces  to  2  1/2 
pounds,  except  one,  whose  weight  remained  the  same. 
Not  one  reported  headache,  constipation,  nor  any  form  of 
digestive  discomfort,  and  the  single  one  who  was  consti- 
pated at  the  beginning  of  the  experiment,  found  his  bowels 
more  regular  in  five  days.  Not  one  of  the  eight  suffered  a 
single  qualm  of  indigestion. 

A  more  detailed  and  exact  experiment  as  to  the  effects  of 
copious  water-drinking  has  been  reported  by  C.  C.  Fowler 
and  P.  B.  Hawk,  who  placed  a  young  man  on  a  normal, 
constant  diet,  and  by  means  of  a  preliminary  period  of 
sufficient  length,  he  was  brought  to  a  condition  of  ap- 
proximate nitrogen  equilibrium.  At  that  point,  1000  c.c. 
of  water  was  added  to  each  meal,  and  continued  thus 
through  a  period  of  five  days.  Immediately  following  this 
period  came  a  final  period  of  eight  days,  during  which  the 
original  normal  diet  was  again  maintained,  and  the  after 
effects  of  copious  water  ingestion  observed. 

The  urine  was  collected  in  twenty-four-hour  samples, 
while  the  feces  were  collected  in  period  samples.  The  foods 
with  the  exception  of  milk  were  analyzed  before  the  ex- 


EXPERIMENTS   IN   WATER   DRINKING  265 

periment  began,  after  preparing  a  satisfactory  sample  of 
each  of  the  foods  to  be  used.  The  milk  was  analyzed  at 
frequent  intervals  during  the  experiment.  Thus,  accurate 
knowledge  of  the  income  and  outgo  of  nitrogen  being 
obtained,  reliable  conclusions  were  made  possible. 

These  observers  followed  up  this  experiment  assiduously, 
and  brought  out  a  wealth  of  detail  not  before  equalled  by 
any  similar  effort.  Their  conclusions,  which  seem  well 
borne  out  by  their  figure  indicate  that  the  daily  drinking  of 
3  liters  of  water  with  meals,  for  a  period  of  five  days,  by  a 
man  twenty-two  years  of  age,  who  was  in  a  condition  of 
nitrogen  equilibrium  through  the  ingestion  of  a  uniform 
diet,  was  productive  of  the  following  findings: 

(i)  An  increase  in  body  weight,  aggregating  2  pounds  in 
five  days. 

(2)  An  increased  excretion  of  urinary  nitrogen,  the  excess 
nitrogen  being  mainly  in  the  form  of  urea,  ammonia,  and 
creatin. 

(3)  A  decreased  excretion  of  creatinin  and  the  coincident 
appearance  of  creatin  in  the  urine.  The  decreased  creatinin 
output  is  beheved  to  indicate  that  the  copious  water  drink- 
ing has  stimulated  protein  catabolism.  The  appearance  of 
creatin  is  considered  evidence  that  the  water  has  caused 
a  partial  muscular  disintegration  resulting  in  the  release  of 
creatin,  but  not  profound  enough  to  yield  the  total  nitrogen 
content  of  the  muscle.  The  output  of  creatin  is,  therefore, 
out  of  all  proportion  to  the  increase  in  the  excretion  of 
total  nitrogen. 

(4)  An  increased  output  of  ammonia,  which  is  inter- 
preted as  indicating  an  increased  output  of  gastric  juice. 

(5)  A  decreased  excretion  of  feces  and  of  fecal  nitrogen, 
the  decrease  of  fecal  nitrogen  being  of  sufficient  magnitude 
to  secure  a  lowered  excretion  of  both  the  bacterial  and  the 
non-bacterical  nitrogen. 

(6)  A  decrease  in  the  quantity  of  bacteria  excreted  daily. 

(7)  An  increase  in  the  percentage  of  total  nitrogen 
appearing  as  bacterial  nitrogen. 


266  HYDROTHERAPY   IN   GASTROINTESTINAL  DISEASES 

(8)  A  lower  creatinin  coefficient. 

(9)  A  more  economical  utilization  of  the  protein  con- 
stituents of  the  diet. 

(10)  The  general  conclusion  to  be  reached  as  the  result 
of  this  experiment  is  to  the  effect  that  the  drinking  of  a 
large  amount  of  water  with  meals  is  attended  with  many- 
desirable  and  no  undesirable  features,  except  in  certain 
indicated  exceptions. 

Noting  the  decrease  in  the  excretion  of  both  bacterial  and 
non-bacterial  nitrogen  in  the  feces  during  copious  water- 
drinking,  followed  by  a  further  decrease  during  a  post- 
water  period  of  low  water  ingestion,  a  series  of  studies  were 
entered  into  by  W.  M.  Hattrem  and  P.  B.  Hawk  to  demon- 
strate in  an  exact  and  scientific  manner  the  effect  of  copious 
and  moderate  water-drinking  with  meals  upon  intestinal 
putrefaction. 

The  salient  features  of  these  studies,  as  reported  in  the 
Archives  of  Internal  Medicine,  will  be  given. 

Experiments  of  three  kinds  were  conducted.  The 
influence  of  copious  water- drinking  with  meals  was  first 
investigated,  followed  by  a  study  of  moderate  water-drink- 
ing, and  finally  copious  water-drinking  in  a  man  accustomed 
to  drink  large  quantities  of  water  at  meal-time. 

The  urine  during  this  experiment  was  examined  for  in- 
dican  according  to  the  quantitive  method  of  EUinger,  and 
for  ethereal  sulphate  according  to  the  method  of  Folin. 

Omitting  the  very  extensive  and  convincing  tables  of 
these  investigators,  which  show  "an  infinite  capacity  for 
taking  pains,"  their  conclusions  are  as  follows: 

(i)  The  drinking  of  copious  (1000  c.c.)  or  moderate 
(500  c.c.)  volumes  of  water  with  meals  decreased  intestinal 
putrefaction  as  measured  by  the  urinary  indican  output. 

(2)  Copious  water- drinking  caused  a  more  pronounced 
lessening  of  the  putrefactive  processes  than  did  moderate 
water-  drinking . 

(3)  In  copious  water-drinking  the  total  ethereal  sulphate 
output  was  increased  coincidently  with  the  decrease  in  the 


EXPERIMENTS   IN   WATER   DRINKING  267 

indican  output.  This  observation  furnishes  strong  evi- 
dence in  favor  of  the  view  that  indican  has  an  origin  dif- 
ferent from  that  of  other  ethereal  sulphates,  and  that  they 
cannot  be  correctly  considered  as  indexes  of  the  same 
metabolic  process.     ■ 

(4)  When  EUinger's  method  is  employed,  the  determina- 
tion of  indican  should  be  made  on  fresh  urine  before  any 
preservative  has  been  introduced.  Especially  is  this  true 
when  thymol  is  to  be  used. 

(5)  The  decreased  intestinal  putrefaction  brought  about 
through  the  ingestion  of  moderate  or  copious  quantities  of 
water  at  mealtime  is  probably  due  to  a  diminution  of  the 
activity  of  indol-forming  bacteria  following  the  accelerated 
absorption  of  the  products  of  protein  digestion,  and  the 
passage  of  excessive  amounts  of  strongly  acid  chyme  into 
the  intestines. 

I  have  entered  at  length  into  the  discussion  of  these 
■experiments  and  the  deductions  to  be  drawn  from  them 
because  of  their  great  practical  importance.  The  presence 
■of  an  abundance  of  water  during  the  busy  period  of  diges- 
tion is  as  necessary  in  efficient  "bodily  housekeeping"  as 
it  is  to  the  housewife  in  her  domestic  housekeeping. 

This  error  concerning  the  influence  of  water-drinking  at 
meals  is  widespread  and  firmly  entrenched,  and  should  be 
•combatted  by  every  earnest  physician. 

As  the  first  principle  of  hydrotherapy,  therefore,  each 
patient  should  be  instructed  to  drink  copious  amounts  of 
water  with  each  meal,  unless  it  is  positively  and  logically 
■contraindicated.  With  this  injunction  should  be  given  an 
■explanation  of  the  reason,  as  well  as  an  assurance  that  the 
water  will  not  be  harmful,  otherwise  some  disciple  of  the 
ancient  traditions  against  water  will  frighten  the  patient 
by  dire  prophecies  of  the  danger  that  will  ensue,  so  that  the 
liberal  amount  will  not  be  drunk,  or,  if  it  is,  will  be  taken  with 
a  mental  attitude  of  apprehension. 

The  uses  of  water  in  lavage  and  intestinal  irrigation  have 


268  HYDROTHERAPY   IN    GASTROINTESTINAL   DISEASES 

been  described,  and  the  reader  is  referred  to  previous 
chapters. 

A  few  of  the  more  exacting  methods  of  hydrotherapy  in 
digestive  diseases  can  be  employed  only  in  a  properly 
equipped  institution  and  with  trained  assistants.  Most  of 
them,  however,  are  available  at  home,  and,  by  the  use  of 
some  ingenuity  on  the  part  of  the  physician  or  patient,  can 
be  successfully  applied. 

Nausea. — In  nausea  arising  from  an  overloaded  stomach, 
or  where  an  excess  of  sticky  mucus  is  constantly  rising  in 
the  throat,  the  ingestion  in  rapid  succession  of  several 
glasses  of  tepid  water  so  that  it  will  be  expelled  with  some 
force,  will  give  much  relief.  The  patient  should  be  ad- 
monished not  to  be  afraid  to  drink  enough  (three  to  six, 
or  even  ten  glasses),  for  when  sufficient  has  been  drunk,  it 
will  be  evacuated.  Sometimes,  where  the  emesis  does  not 
prove  too  exhausting,  this  procedure  may  be  repeated 
several  times  until  the  water  comes  back  clear.  This  is  a 
substitute  for  gastric  lavage  where  the  latter  is  not  available. 

This  method  of  "washing  the  stomach"  is  also  useful  in 
the  nausea  following  an  alcoholic  debauch. 

After  the  stomach  has  been  completely  emptied,  there 
may  be  then  given  either  small  pieces  of  ice,  or  very  hot 
water  may  be  sipped  slowly.  The  application  of  towels 
wrung  out  in  ice  water,  and  frequently  applied  to  the  neck 
is  a  domestic  remedy,  but  a  good  one.  Hot  moist  com- 
presses applied  to  the  epigastrium  are  helpful,  and  a  hot  foot 
bath  often  has  a  quieting  effect  on  the  upset  stomach. 

Quite  useful  is  the  alternate  douche,  which  resembles  the 
Scotch  douche  in  that  it  employs  both  hot  and  cold  water; 
but  differs  from  it  in  that  the  Scotch  douche  consists  of  a 
single  application  of  water  at  each  temperature — first  hot 
then  cold — while  in  the  alternate  douche,  hot  and  cold  water 
are  repeatedly  applied  in  alternation.  This  alternation 
may  be  continued  as  long  as  may  be  thought  necessary,  and 
is  indicated  in  nausea  from  nephritis  or  the  nausea  in 
nervous  anorexia. 


t  HYDROTHERAPY  FOR  ANOREXIA  269 

This  is  quite  an  energetic  procedure,  and  judgment  must 
be  exercised  as  to  the  temperature  of  the  alternating  currents 
of  water  and  the  relative  length  of  application  of  each. 

Another  valuable  aid  is  found  in  the  employment  of 
cold  abdominal  compresses,  sometimes  called  "Neptune's 
girdle,"  in  which  the  abdomen  is  encircled  by  a  thick 
towel  of  liberal  proportions,  saturated  with  cold  water. 
This  may  be  removed  and  resaturated  every  one  or  two 
hours.  Ice-water  compresses  or  ice  bags  to  the  epigastrium 
may  be  used  for  nausea  in  robust  patients,  but  where  there 
is  weak  heart  action,  or  where  the  cold  is  disagreeable  to 
the  patient,  the  hot  applications  are  generally  preferable. 

It  may  be  advanced  as  a  general  principle  in  hydro- 
therapy that  the  sensations  of  the  patient  should  form  an 
important  criterion  in  choosing  the  hot  or  cold  applications. 
Some  there  are  whose  very  nature  seems  to  revolt  at  the  use 
of  cold,  and  it  is  harmful  to  force  them  to  endure  it.  Others 
find  cold  applications  both  soothing  and  comforting,  and 
these  will  be  benefitted  by  such.  As  the  physiologic  effect 
of  the  extremes  of  heat  and  cold  are  practically  the  same, 
this  choice  is  logical  and  permissible. 

In  some  of  these  patients  who  are  hyper-sensitive  to  cold, 
the  alternating  douche  may  be  first  used  with  the  warm  cur- 
rent greatly  in  preponderance ;  gradually  increasing  the  cold 
interval  until  they  become  accustomed  to  it. 

The  alternate  douche  is  probably  the  most  exciting  of  all 
hydriatic  procedures,  combining  with  the  heat  the  secon- 
dary stimulating  effects  of  the  cold,  and,  through  the  re- 
moval of  the  heat  accumulated  by  the  skin  during  the  hot 
application,  the  susceptibility  of  the  skin  is  renewed,  its 
reflex  activities  maintained,  and  thus  the  excitant  effect  of 
the  hot  applications  are  intensified  and  prolonged. 

Anorexia. — This  condition,  especially  the  nervous  variety, 
may  be  aided  by  an  ice-bag  over  the  stomach  half  an  hour 
before  meals,  followed  by  cold-mitten  friction,  if  it  can  be 
administered  by  one  of  experience.  Hot  and  cold  gastric 
lavage,  as  advocated  by  some,  is,  in  my  opinion,  rather  a 


270  HYDROTHERAPY   IN   GASTROINTESTINAL  DISEASES 

drastic  procedure,  unless  called  for  to  meet  other  and  more 
pressing  conditions. 

A  very  small  cold  enema,  or  cold  rectal  irrigation  be- 
fore breakfast  is  recommended  in  some  instances  by 
Dr.  Kellogg,  but  the  good  effect,  if  obtained,  is  probably 
psychic. 

A  thorough  gastric  lavage  with  a  nitrate  of  silver  solution 
(i  to  5000)  on  alternate  days  has  seemed  to  exercise  a 
decidedly  good  effect  in  several  cases  of  obstinate  anorexia 
under  my  observation. 

Acute  Gastritis. — In  some  of  these  acute  irritative  states 
of  the  gastric  mucosa,  no  water  or  any  other  substance  will 
be  retained,  and  it  is  necessary  to  use  enemas  for  several 
days  for  both  food  and  water.  During  this  time,  however, 
much  may  be  accomplished  by  hot  compresses  over  the 
bowels  every  two  hours,  and  by  both  hot  foot  baths  and  hot 
leg  packs  at  intervals  of  every  three  to  six  hours. 

The  vomiting  of  acute  gastritis  calls  for  much  the  same 
hydrotherapeutic  procedures  as  vomiting  from  other  causes. 
In  addition  may  be  employed  the  hot  and  cold  trunk  pack, 
and,  if  the  patient  is  not  averse,  an  ice-bag  to  the  spine 
opposite  the  stomach.  An  excellent  measure  also  is  the 
revulsive  compress.  This  differs  from  the  alternating  hot 
and  cold  application  in  that  the  hot  compress  is  kept  on 
from  four  to  five  minutes,  while  the  cold  is  permitted  only 
fifteen  or  twenty  seconds. 

Where  the  gastritis  is  accompanied  by  fever,  the  hot 
blanket  pack,  followed  by  a  cold  half-pack  is  generally 
helpful.     Cold  applications  alone  are  seldom  indicated. 

Chronic  Gastritis. — In  this  pathologic  condition  hydro- 
therapy finds  a  useful  field.  For  the  excessive  accumula- 
tion of  mucus,  a  gentle  lavage  once  daily,  lessened  to  once 
on  alternate  days,  as  improvement  sets  in,  is  nearly  always 
indicated. 

For  the  local  discomfort  there  may  be  given  hot  fomenta- 
tions or  compresses  several  times  daily,  with  a  Scotch 
douche  once  daily,  if  the  patient  is  robust.     For  the  flatu- 


HYDROTHERAPY   IN   GASTRIC   DISORDERS  271 

lence  and  gaseous  eructations,  either  hot  or  cold  compresses 
to  the  epigastrium  may  be  employed,  with  an  ice-bag  to 
the  spine  two  or  three  times  daily  in  addition  to  the  lavage. 
Occasionally  a  pint  of  quite  hot  water,  sipped  half  an  hour 
before  meals  prevents  the  flatulence.  Abdominal  flatu- 
lence is  generally  controlled  by  hot  compresses  over  the 
whole  abdomen,  and  an  occasional  asafetida  enema,  sent 
rather  high  up  the  bowel. 

Achylia  Gastrica.  (Hypochlorhydria) . — Cold  douche 
over  stomach,  and  cold  percussion  daily,  if  the  patient  can 
stand  it.  Cold  wet  girdle  over  epigastrium  half  an  hour 
before  meals,  and  kept  on  about  fifteen  minutes.  A  small 
cold  enema  to  be  retained,  and  taken  two  hours  after  eating, 
is  said  to  increase  the  motility  of  the  stomach  (Kellogg). 

In  addition,  other  procedures,  mechanical  and  electrical 
are  indicated  for  diminished  or  absent  gastric  juice, 

Hyperchlorhydria. — This  is  generally  a  symptom  of  an 
underlying  lesion,  but  hyperchlorhydria  itself,  whether 
primary  or  secondary,  can  be  greatly  helped  by  rational 
measiu"es  of  hydrotherapy,  while  many  of  the  distressing 
manifestations  of  hyperacidity  may  be  alleviated. 

The  procedures  are  nearly  opposite  those  in  the  previous 
condition.  Revulsive  compresses  once  or  twice  daily,  an 
hour  before  eating,  or,  if  this  is  not  agreeable,  a  con- 
tinuous heating  compress  over  the  epigastrium.  Cold 
douches  over  the  stomach  or  spine  opposite  the  stomach  are 
contraindicated,  though  a  hot  douche  or  fomentation  over 
the  spine  is  serviceable.  Hot  water  in  limited  quantity 
may  be  sipped  a  short  time  before  each  meal. 

For  the  pain,  which  accompanies  the  excess  of  free  acid, 
hot  fomentations  may  be  applied  for  fifteen  minutes  when 
this  appears,  followed  by  hot  compresses  to  be  worn  until 
the  next  meal. 

The  bowels  should  be  kept  freely  open  with  warm  enemas 
given  daily. 

Gastroptosis  or  Enteroptosis. — This  calls  for  general  tonic 
measures,    combined   with    massage    and    supportive    ap- 


272  HYDROTHERAPY   IN    GASTROINTESTINAL   DISEASES 

pliances.  The  fan  douche  may  be  used  two  or  three  times 
daily,  and  is  a  modification  of  the  jet  douche,  attained  by 
placing  the  thumb  over  the  nozzle  delivering  the  jet,  break- 
ing it  into  a  fan-shaped  stream.  This  is  usually  cool  or 
cold. 

Dr.  George  R.  Lockwood  advocates  the  following  pro- 
cedure : 

About  II  o'clock  a.  m.  a  warm  or  hot  bath  is  given  for 
five  minutes.  This  is  followed  by  a  spinal  douche  at  100° 
to  102°  F.  for  ten  minutes  at  15  to  20  pounds  pressure. 
The  patient  is  then  placed  in  bed  and  a  hot  wet  flannel 
compress  or  one  of  spongiopiline  sufficiently  large  to  cover  a 
good  portion  of  the  abdomen  is  placed  on  the  epigastrium. 
This  is  kept  hot  by  a  covered  electric  pad,  and  is  changed 
every  two  hours  by  day  and  once  at  night.  The  whole 
application  is  to  be  tightly  applied  by  an  electric  binder. 

Dilatation  of  Stomach. — Avoid  drinking  large  quantities 
of  fluid  at  meal-time  or  any  other  time.  This  is  one  of  the 
few  conditions  where  large  draughts  of  water  are  contrain- 
dicated,  as  the  relaxed  and  atonic  walls  of  the  stomach  are 
unable  to  evacuate  the  fluid  promptly. 

Lavage  once  daily  is  indicated,  and  if  possible  the  patient 
is  to  eat  a  rather  early  supper  and  have  the  stomach  thor- 
oughly cleaned  of  all  food  accumulation  just  before  bed- 
time. The  rest  overnight  will  greatly  help.  This  rest  in 
the  empty  state  for  eight  or  ten  hours  is  strongly  advocated 
by  J.  W.  Weinstein. 

Externally  the  cool  or  cold  fan  douche  is  indicated,  with 
cold  epigastric  compresses,  without  impervious  covering, 
changed  every  three  or  four  hours.  In  addition  there 
may  be  applied  once  daily  a  hot  blanket  pack,  followed 
by  a  short,  cool  fan  douche. 

Should  there  be  hiccough  due  to  either  irritation  or  stasis 
of  food,  in  addition  to  faradization  with  one  electrode 
over  the  spine  and  the  other  over  the  stomach,  there  should 
be  employed  hot  and  cold  alternate  gastric  compresses, 
followed  by  an  ice-bag  to  the  epigastrium  and  back  of  neck. 


HYDROTHERAPY   FOR   CONSTIPATION  273 

The  patient  may  also  slowly  sip  1/2  pint  of  ice-cold  car- 
bonated water,  holding  the  breath  for  half -minute  periods, 
and  with  pressure  of  hands  over  the  stomach  force  it  up 
against  the  diaphragm. 

Constipation. — In  few  digestive  disorders  does  hydro- 
therapy exercise  a  more  happy  effect  than  in  this.  Apart 
from  the  various  enemas,  which  have  been  described,  the 
following  procedures,  as  suggested  by  Hinsdale,  may  be 
used: 

In  fairly  robust  individuals,  whose  circulation  is  good, 
the  application  of  a  cold  pack  or  compress  to  the  abdomen 
every  morning  may  be  given  a  preliminary  trial.  This 
cold  compress  should  be  changed  once  or  twice  during  the 
ten  or  fifteen  minutes  of  the  application.  Where  there  are 
suitable  appliances,  a  cold  douche  at  65°  or  60°  F.  may  be 
applied  for  fifteen  or  twenty  minutes  with  about  20  pounds 
pressure.  This  will  probably  give  better  results  in  ob- 
stinate cases  than  the  compress  or  pack.  The  reaction 
which  ensues  is  accompanied  by  an  increase  of  blood  in  the 
abdominal  vessels,  thus  favoring  functional  activity. 

In  patients  not  so  robust,  and  with  sluggish  circulation, 
a  hot  douche  or  warm  compress  may  be  made  at  first,  and 
later  on  the  temperature  may  be  gradually  lowered  from 
day  to  day. 

Compresses  are  more  suitable  for  old  and  feeble  patients 
than  the  more  energetic  treatment  by  douches.  The  cold 
thick  compress,  or  "Neptune's  girdle"  placed  over  the 
abdomen,  and  renewed  every  four  hours,  affords  quite  a 
marked  stimulus  without  discomfort  or  depression. 

In  that  form  of  constipation  denominated  spastic,  ac- 
companied by  muscular  rigidity,  hot  fomentations  must 
be  employed.  They  should  be  of  generous  dimensions, 
extending  well  beyond  the  borders  of  the  irritable  and 
painful  area,  should  be  wrung  dry  to  avoid  blistering,  and 
should  be  changed  every  five  or  ten  minutes.  They  should 
be  covered  with  rubber  or  any  material  that  will  retain  the 
heat.     One,  two,  or  more  layers  of  thick  cloth,  flannel,  or 


274  HYDROTHERAPY   IN    GASTROINTESTINAL   DISEASES 

felt,  make  a  satisfactory  medium  to  carry  the  water.  When, 
in  addition  to  heat,  a  counter-irritant  is  desired,  a  small 
amount  of  turpentine  or  mustard  may  be  added  to  the 
water  for  the  fomentations.  A  hot-water  coil  or  a  covered 
electric  compress  may  be  tried,  but  the  heat  without  the 
moisture  is  not  so  efficacious. 

When  constipation  assumes  the  chronic  form,  unless 
obstructive,  it  generally  resolves  itself  into  one  of  two 
forms — atonic  or  spastic.  These  two  forms  require  certain 
variations  in  their  management. 

In  the  atonic  variety  every  measure  tending  to  improve 
the  tone  of  the  muscular  system  is  called  for.  If  possible, 
the  hot-air  or  electric  cabinet  should  be  used  to  produce 
perspiration,  followed  by  the  circular  jet,  Scotch,  and  fan 
douches.  These  measures  should  then  be  followed  up  by 
abdominal  and  general  massage,  if  skilful  services  of  the  sort 
are  available;  otherwise,  they  should  not  be  attempted. 
Aimless  and  desultory  rubbing  of  the  abdomen  accomplishes 
no  good. 

Many  of  these  stubborn  cases  of  chronic  atonic  con- 
stipation are  really  brought  about  by  kinks  and  torsions  on 
prolapsed  abdominal  viscera,  and  in  such  conditions,  me- 
chanical support,  or  in  extreme  cases,  surgical  correction, 
will  be  required.  After  that,  hydrotherapy  will  be  of 
more  tangible  assistance.  To  blindly  employ  this  admir- 
able branch  of  therapeutics  in  conditions  where  surgery  or 
mechano-therapeutics  is  logically  indicated,  is  to  court 
failure,  and  tends  to  bring  hydrotherapy  into  undeserved 
disrepute. 

Spastic  constipation  is  found  more  frequently,  if  carefully 
sought.  In  the  female  probably  25  per  cent,  of  the  cases 
are  of  this  form;  and  many  of  the  refractory  and  per- 
sistent instances  of  long-standing  constipation  are  of  this 
type.  As  the  treatment  of  spasticity  is  diametrically 
opposite  to  atony,  it  is  not  difficult  to  understand  why  so 
many  patients  are  treated  for  long  periods  without  success. 
It  is  most  frequently  found  in  neurasthenic  and  hysteric 


HYDROTHERAPY    FOR    CONSTIPATION  275 

individuals,  who  are  weak,  poorly  nourished,  somewhat 
pale  and  anemic,  and  in  the  third  or  fourth  decade  of  life. 
It  also  occurs  when  a  secondary  entercolitis,  or  the  abuse 
of  laxatives  has  irritated  the  colon,  so  that  a  persistent 
hypertonicity  of  its  musculature  has  developed.  In  in- 
dividuals temperamentally  nervous  this  stage  sets  in 
considerably  earlier  than  in  those  whose  nervous  systems 
are  well  poised. 

An  intelligent  syndrome  of  the  malady  should  first  be 
obtained  in  order  to  outline  a  rational  course  of  treatment. 

As  these  spasms  sometimes  develop  on  the  basis  of 
atony,  every  occasion  for  exciting  them  must  be  avoided. 
Every  irritation  of  the  abdomen,  especially  massage,  which 
is  useful  in  the  atonic  form  of  constipation  must  be  avoided. 
Warm  or  hot  sitz-baths  may  be  taken  for  from  fifteen  to 
twenty  minutes  one  or  more  times  daily.  Frequent  hot 
compresses,  applied  to  the  abdomen,  lessen  the  spasm  and 
relieve  the  colic.  Cold  applications  are  generally  con- 
traindicted.  In  this  spastic  condition  the  oil  enemas,  in- 
jected at  night  and  retained  till  morning,  bring  about  most 
gratifying  results.  The  oil,  employed  this  way,  acts  as  a 
sedative  on  the  spasm  of  the  intestinal  muscles,  and  should 
therefore,  remain  in  contact  with  them  as  long  as  possible. 

Some  instances  of  severe  and  obstinate  constipation  arise 
in  the  presence  of  fissured  anus,  where  the  sphincters  are 
spasmodically  contracted,  and  the  passage  of  intestinal 
contents  inflicts  agony. 

Some  of  these  siifferers,  dreading  the  pain  of  defecation, 
put  it  off  for  days  at  a  time  until  the  large  intestine  is 
packed  with  a  desiccated  mass  of  hardened  feces. 

These  patients  should  receive  first  an  injection  of  cotton- 
seed oil,  which  should  remain  in  the  bowel  for  three  to  six 
hours.  This  should  be  followed  by  several  enemas  of 
warm  water  with  soap-suds,  so  as  to  soften  and  bring  away 
the  hardened  mass.  It  is  very  much  better  to  use  a  number 
of  small  enemas  than  to  attempt  to  flush  out  the  intestine 
with  a  single  large  one.     After  the  patient  becomes  weary, 


276  HYDROTHERAPY   IN    GASTROINTESTINAL   DISEASES 

another  oil  enema  may  be  introduced,  and  this  procedure 
repeated  until  the  colon  and  rectum  are  empty. 

The  fissure  should  receive  appropriate  attention,  and  the 
patient  should  be  earnestly  admonished  to  keep  the  stools 
soft  by  the  use  of  oil  at  night  and  warm  water  the  following 
morning,  until  the  soreness  has  disappeared  and  the  spasm 
completely  relaxed. 

Nervous  Dyspepsia. — This  term  is  at  present  in  disre- 
pute, some,  especially  those  with  a  decided  siurgical  bias, 
denying  absolutely  there  are  ever  any  marked  symptoms  of 
indigestion  without  underlying  organic  lesions. 

The  various,  forms  of  nervous  and  psychic  indigestion 
will  be  discussed  in  another  chapter,  but,  admitting  that 
there  are  certain  mainfestations  of  indigestion  due  to 
nervous  instability  or  irritability,  there  will  be  found  in 
hydrotherapy  a  potent  auxiliary  to  other  methods  of 
treatment. 

The  symptoms  are  many,  and  sometimes  shift  from  one 
syndrome  to  another  with  kaleidoscopic  rapidity.  It  is 
surprising  what  incongruous  groupings  of  pains  and  dis- 
comforts are  described  to  the  physician,  while  these 
neurasthenics  almost  demand  that  each  pain  or  ache  re- 
ceives separate  and  distinct  attention.  The  hydrotherapy, 
therefore,  will  be  principally  symptomatic,  and  should 
not  displace  rational  methods,  surgical  or  otherwise,  for 
the  cure  of  actual  and  tangible  disease. 

For  the  general  malaise  and  weakness,  graduated  cold 
baths  may  be  administered  twice  daily,  plus  a  brief  per- 
cussion douche  to  the  spine.  For  the  spinal  irritability, 
fomentations  at  night  to  the  back,  followed  by  a  heating 
spinal  compress  to  be  worn  till  morning,  is  of  benefit. 
"Neptune's  girdle"  also  may  be  used  at  times. 

For  the  pyrosis,  eructations,  and  regurgitation  of  food, 
there  may  be  given  twice  or  three  times  daily  fomentations 
over  the  epigastrium,  followed  by  a  heating  compress  most 
of  the  time  during  the  interval,  without  impervious  cover- 
ing, and  renewing  every  three  or  four  hours. 


HYDROTHERAPY  FOR  DYSENTERY  277 

The  cold  extremities  call  for  the  running  cold  foot  bath, 
followed  by  the  hot  leg  pack.  Brisk  massage  of  the 
extremities  is  also  helpful. 

The  frequent  headache,  which  nearly  always  accompanies 
nervous  indigestion,  generally  yields  to  hot  and  cold  head 
compresses  with  massage  to  head  and  neck.  In  this 
condition  the  cool  compresses  are  desired  more  than  any 
other,  especially  if  the  face  is  flushed  and  hot,  and  the  eyes 
suffused. 

For  the  abdominal  weight  and  tenderness,  which  is  com- 
monly associated  with  excessive  peristalsis  and  gurgling, 
there  are  indicated  a  hot  fan  douche  to  the  whole  abdomen, 
followed  by  revulsive  sitz-bath.  These  may  be  followed  by 
fomentations  twice  daily,  or  the  wet  girdle  protected  with 
an  impervious  covering. 

It  is  a  very  good  idea  to  multiply  and  prolong  these 
procedures,  if  the  patient  has  the  time,  for  they  take  the 
mind  away  from  its  introspective  trend,  and  occupy  it  with 
novel  and  interesting  sensations. 

The  whole  rationale  of  hydrotherapy  in  nervous  dys- 
pepsia consists  in  improving  nerve  tone,  allaying  general 
nervous  irritability,  lessening  gastric  irritation,  and  im- 
proving the  general  nutrition  by  generous  diet,  abundance 
of  fresh  air,  cheerful  environment,  and  appropriate  and 
well-directed  measures,  as  indicated  above. 

Acute  Dysentery. — The  patient  should  be  kept  in  bed, 
and  there  should  be  applied  the  hot  blanket  pack,  the  hot 
hip  and  leg  pack,  together  with  hot  abdominal  com- 
presses. Should  there  be  much  soreness  and  pain,  a  little 
turpentine  may  be  added  to  the  water  in  which  the  hot  com- 
presses are  wrung.  Some  advocate  the  cold  sitz-bath  of 
fifteen  to  twenty  minutes  with  a  simultaneous  hot  foot 
bath.  This  I  do  not  approve.  Cold  irrigations  of  the 
rectum  for  the  tenesmus  is  another  procedure  which  has 
not  yet  yielded  good  results  in  my  observation.  Very  hot 
irrigations — iio°  to  120°  F.,  as  recommended  by  Jamison 


278  HYDROTHERAPY   IN    GASTROINTESTINAL   DISEASES 

have  proved  much  more  satisfactory,  mitigating  both  the 
tenesmus  and  soreness. 

Chronic  Dysentery. — While  in  this  condition,  rest  in  bed 
may  not  be  practicable,  but  a  quiet  and  sedate  mode  of 
life  will  be  advantageous.  Many  of  these  patients  find  that 
their  bowels  move  but  seldom  when  they  can  minimize  their 
exercise.  Generally,  also,  there  are  organic  lesions  of  the 
intestines  that  require  some  special  treatment  before  any 
form  of  hydrotherapy  can  be  effective.  Chronic  dysentery 
from  the  ameba  coli  may  be  cited  as  an  instance  of  the 
foregoing. 

Hot  compresses,  revulsive  sitz-baths,  or  hot  applications 
of  any  kind  are  seldom  indicated,  unless  a  hot  enema  to 
occasionally  clear  out  the  rectum  or  descending  colon. 
Better  are  the  graduated  cold  baths  twice  daily,  and  the 
cold  rubbing  sitz-bath. 

For  chronic  muco-membranous  colitis  the  hydrotherapy 
is  similar  to  that  in  nervous  dyspepsia,  except  that  the 
general  applications  need  not  include  the  epigastric  region. 
This  condition  being  to  a  great  extent  a  neurosis,  all 
measures  that  make  for  better  nerve  and  mucular  tone, 
improved  nutrition,  and  more  buoyant  mentality  are 
indicated. 

Cholera  Nostras. — In  this  very  acute  disorder,  energetic 
hydrotherapy  is  not  only  curative,  but  sometimes  actually 
saves  the  life  of  the  patient.  For  the  excessive  vomiting, 
there  may  be  administered  small  pieces  of  cracked  ice,  while 
over  the  stomach  is  an  ice-bag,  and  an  ice  compress  to  the 
throat.  There  may  be  an  ice-bag  placed  over  the  spine, 
but,  if  weakness  supervenes,  some  of  the  applications  will 
have  to  be  changed  to  hot.  For  the  excessive,  and  some- 
times explosive,  diarrhea,  are  indicated  fomentations  over 
the  abdomen  every  two  hours,  each  lasting  twenty  minutes, 
while  between,  the  heating  compress,  renewed  every  twenty 
or  thirty  minutes.  If  the  temperature  is  over  102^,  a  pro- 
longed neutral  bath  or  hot  blanket  pack,  followed  by  cold 
friction  or  cold  towel  rub,  will  bring  it  down.     For  the 


HYDROTHERAPY  FOR   JAUNDICE  279 

collapse,  which  is  sometimes  grave,  there  may  be  employed 
a  hot  blanket  pack,  followed  by  brief  cold-mitten  friction, 
and  an  ice-bag  over  the  heart,  if  the  latter  does  not  prove 
uncomfortable  to  the  patient.  In  the  meanwhile  other 
appropriate  remedies  should  be  brought  into  service,  for 
cholera  nostras  brooks  no  therapeutic  dalliance. 

Acute  Appendicitis. — Hydrotherapy  in  this  inflammatory 
condition  is  of  marked  benefit,  but  the  physician  should  be 
constantly  on  the  alert,  lest  serious  complications  re- 
quiring prompt  surgical  intervention  suddenly  arise. 

While  keeping  in  bed,  there  should  be  given  hot  enemas 
every  four  hours  until  the  bowels  seem  fairly  empty,  fo- 
mentations over  abdomen  for  fifteen  minutes  every  hour, 
with  hot  compresses  in  the  interval.  As  the  pain  and 
inflammation  subside,  the  intervals  between  the  fomenta- 
tions and  compresses  may  be  prolonged,  though  fomenta- 
tions at  night,  followed  by  a  heating  compress  over  the 
right  iliac  region,  may  be  kept  up  for  months,  or  until  every 
trace  of  soreness  disappears. 

Jaundice. — For  the  pain  or  uneasiness  in  the  right  hy- 
pochondriac region,  fomentations  may  be  used  over  the 
stomach  and  liver  for  fifteen  minutes  every  two  hours, 
followed  by  heating  compress.  The  bowels  should  be 
flushed  by  a  copious  hot  irrigation  with  a  recurrent  tube 
twice  daily,  followed  by  an  oxgall  enema,  if  the  fecal 
evacuations  are  scanty.  For  the  relief  of  the  discolored 
skin,  a  hot  trunk  pack,  or  a  hot  immersion  bath,  followed 
by  a  cold  towel  rub  is  useful.  The  patient  should  drink 
water  copiously,  and  receive  once  daily  either  a  sweating 
wet-sheet  pack  or  an  electric  light  bath.  For  the  itching, 
which  is  sometimes  most  annoying,  he  may  receive  the 
neutral  saline  bath,  with  very  hot  sponging.  The  treat- 
ment of  the  anorexia,  nausea,  and  general  symptoms  of 
gastric  catarrh  are  the  same  as  for  these  symptoms  in 
chronic  gastritis. 

Gastric  Ulcer. — Apart  from  measures  to  relieve  pain,  to 
tone  the  patient,  and  to  keep  the  bowels  sufficiently  open, 


28o  HYDROTHERAPY   IN    GASTROINTESTINAL   DISEASES 

hydrotherapy  possesses  no  very  wide  range  of  usefulness 
in  this  affection.  I  say  this  advisably,  notwithstanding 
some  authorities  have  advocated  numerous  procedures,  as 
ice  in  the  rectum  to  arrest  hematemesis  (it  does  not),  cold 
water  enemas  under  the  same  mistaken  idea,  or  ice  pills 
given  by  mouth,  which  naturally  cause  warm  water  to 
accumulate  in  the  stomach. 

For  the  gastric  hemorrhage,  either  an  ice-bag  over  the 
stomach,  or,  if  available,  a  cold  coil  over  a  cold  compress 
is  an  effectual  aid,  the  flow  of  ice-water  being  kept  up 
continuously  and  the  application  kept  in  place  over  the 
epigastrium  for  a  week  or  more,  if  the  patient  can  bear  it. 
In  addition,  there  may  be  applied  an  abdominal  pack, 
changed  every  three  hours,  with  an  occasional  coil  of  hot 
water  inserted  in  the  pack.  Early  in  the  morning  the  body 
may  be  rubbed  off  with  a  cloth  wrung  out  of  very  cold 
water,  avoiding  the  chest  and  abdomen,  followed  by  a 
brisk  rub. 

During  convalescence  general  tonic  applications  are 
recommended,  but  I  wish  to  stress  the  caution  that  hydro- 
therapy should  not  be  relied  upon  to  the  exclusion  of  other 
approved  remedial  measures  in  gastric  ulcer  or  hemorrhage. 
This  also  applies  to  duodenal  ulcer. 

Peristaltic  Unrest. — In  this  condition  known  as  the 
peristaltic  unrest  of  Kussmaul,  the  general  hydrotherapy  as 
indicated  in  neurasthenia  and  nervous  dyspepsia  are 
indicated.  The  lower  bowel  should  be  kept  clean  with 
daily  hot  irrigations,  preceded  by  an  asafetida  enema,  if 
there  is  flatulence. 

These  various  procedures  can  be  modified  in  certain  par- 
ticulars to  suit  the  convenience  or  purse  of  the  patient,  or 
the  facilities  possessed  by  the  physician.  Ingenuity  of  the 
part  of  the  latter  can  overcome  the  absence  of  many 
special  appliances,  and,  by  its  exercise,  nearly  all  of  the 
principal  hydrotherapeutic  measures  may  be  instituted  at 
the  patient's  home. 

The  rank  and  file  of  the  regular  profession  have  long 


RATIONAL   HYDROTHERAPY  28 1 

been  indifferent  to  the  beneficent  results  to  be  obtained  by 
the  rational  use  of  water,  thereby  permitting  many  of  its 
most  useful  potentialities  for  good  to  be  arrogated  by 
quacks  and  charlatans. 

To  Baruch  and  Winternitz  and  Kellogg  and  Hinsdale 
and  a  small  number  of  other  laborers  we  owe  a  debt  of 
gratitude  for  investigating  this  subject  in  a  scientific  man- 
ner; for  an  unprejudiced  and  convincing  exposition  of  what 
hydrotherapy  is  and  is  not ;  and  for  spreading  abroad  the 
sane  doctrine  that  a  healthy  body  needs  for  its  best  work 
an  abundance  of  water  internally  and  externally. 


CHAPTER  XII 

PSYCHOTHERAPY  IN  GASTROINTESTINAL 
DISEASES 

The  mechanical  functions  of  the  stomach  and  intestines 
as  well  as  the  chemical  properties  of  the  various  digestive 
juices  are  fairly  well  understood,  and,  though  some  of  the 
intermediate  steps  in  the  metabolism  of  different  food 
elements  are  unexplained,  we  can  at  least  calculate  their 
potential  value  in  Nature's  constructive  housekeeping. 

The  influence  of  the  emotions,  however,  has  been  a  sub- 
ject of  study  and  comment  from  the  earliest  antiquity,  for 
in  Ecclesiastes  we  find  that  "A  merry  heart  doeth  good 
like  medicine,"  and  also  "Better  a  dinner  of  herbs  where 
love  is  than  a  stalled  ox  and  hatred  therewith."  I  might 
also  mention  a  familiar  example  in  Semitic  history — Job, 
with  his  cell-exhaustion  from  mental  strain  and  pertubation, 
his  autoinfection,  and  consequent  malassimilation. 

As  to  the  specific  influence  of  the  emotions  over  digestion 
and  nutrition,  I  might  say  that  our  viewpoint  has  only 
within  the  last  two  decades  assumed  a  scientific  aspect. 
Beaumont  accomplished  much  pioneer  work,  revealing  and 
making  plain  many  of  the  digestive  phenomena  previously 
misunderstood.  It  remained  to  Pavlov  and  Cannon  and 
Starling  and  a  few  other  devoted  workers  in  that  field,  to 
demonstrate  this  influence  more  scientifically,  and  to 
elucidate  its  practical  connection  with  many  of  the  most 
vital  of  the  bodily  functions. 

Briefly  stated,  when  food  is  taken,  the  secretion  first 
started  is  due  to  the  sensations  of  eating  and  of  taste — that 
is,  it  is  a  psychic  secretion.  I  might  go  further  by  affirming 
that  the  sensations  of  sight  and  smell  also  exert  a  tangible 


SECRETAGOGUES  283 

influence  in  the  inauguration  of  digestion,  for  nothing  more 
favorably  promotes  the  free  flow  of  "appetite  juices"  than 
a  tastefully  arranged  meal,  clean  linen,  and  other  attractive 
adjuncts,  while  an  agreeable  odor  alone  will  cause  the 
"mouth  to  water"  and  the  digestive  glands  to  pour  out 
their  secretion  in  anticipation  of  the  food  that  is  to  come. 
The  afferent  stimuli,  whose  duty  it  is  to  transmit  messages 
of  gastronomic  interest,  originate  in  the  mouth  and 
nostrils;  while  the  efferent  path,  containing  the  secretory 
fibers,  is  through  the  vagus  nerve.  This  reflex  insures  the 
beginning  at  least  of  gastric  digestion,  though  its  effect  is 
supplemented  by  further  action  arising  in  the  stomach 
itself. 

Certain  foods  contain  substances  called  secretagogues, 
which  are  capable  of  causing  a  flow  of  gastric  juice  when 
taken  into  the  stomach — ^for  instance,  meat  extractives, 
meat  juices,  soups,  highly  seasoned  food,  condiments,  etc. 
Other  foods,  such  as  bread  and  white  of  eggs,  are  lacking  in 
these  ready-formed  secretagogues,  and  have  practically  to 
depend  on  the  psychic  secretions  for  a  large  part  of  their 
digestion.  Experiments  have  shown  that  such  bland 
articles,  when  introduced  into  the  stomach  of  a  dog  while  his 
attention  is  diverted  elsewhere,  or  while  he  is  sleeping, 
produce  no  flow  of  gastric  juice  and  are  not  digested. 

In  addition,  there  are  substances  generated  in  the 
intestinal  and  pancreatic  secretions,  designated  by  Starling 
hormones,  from  a  Greek  word  meaning  to  arouse  or  excite. 
These  hormones  are  influenced  by  the  character  of  the  food 
ingested,  varying  from  a  slight  to  a  potent  effect,  as 
required. 

I  might  say,  without  going  further  into  the  physiology  of 
the  subject,  that  each  of  the  digestive  juices  is  to  a  great 
extent  regulated  in  this  manner,  both  the  amount  and 
specific  quality  being  furnished  according  to  the  chemical 
and  mechanical  needs,  these  needs  being  previously  inter- 
preted by  the  psychic  sensations  evolved.  This  being 
made  plain,  it  is  easy  to  see  how  the  mental  state  of  an 


284         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

individual  may  exert  a  marked  effect  on  both  secretion  and 
motility  of  the  digestive  organs;  how  a  placid  and  cheerful 
frame  of  mind  may  aid  those  organs  concerned  in  the 
upkeep  of  the  body,  or  how  an  unhappy  and  agitated 
mentality  may  set  in  motion  a  long  train  of  stomach  and 
intestinal  ills. 

Instances  of  indigestion  caused  purely  by  nervous  or 
mental  disturbance  are  familiar  to  every  practitioner  of 
experience,  and  are  readily  found  in  literature  of  both  the 
past  and  present. 

In  Burton's  Anatomy  of  Melancholy,  published  in  1621, 
this  accurrence  is  cited:  "A  gentlewoman  of  the  same  city 
saw  a  fat  hog  cut  up,  when  the  entrails  were  opened,  and  a 
noisome  savor  offended  her  nose,  she  much  misliked,  and 
would  not  longer  abide ;  a  physician  in  presence  told  her,  as 
that  hog,  so  was  she,  full  of  filthy  excrements,  and  ag- 
gravated the  matter  by  some  other  loathsome  instances, 
insomuch  this  nice  gentlewoman  apprehended  it  so  deeply 
that  she  fell  forthwith  a- vomiting,  and  was  so  mightily  dis- 
tempered in  mind  and  body,  that  with  all  his  arts  and  per- 
suasions, for  some  months  after,  he  could  not  restore  her 
to  herself  again,  nor  could  she  forget  nor  remove  the  object 
out  of  her  sight." 

Some  years  ago  there  came  under  my  observation  a  lady, 
who  could  not  order  supplies  from  the  butcher  over  the 
telephone,  on  account  of  the  mental  images  produced.  A 
few  years  previously,  she  had  gone  on  a  tour  of  inspection 
through  some  large  slaughter-houses  in  a  western  city,  and 
the  incidents  witnessed  remained  vividly  in  her  memory. 
When,  therefore,  she  attempted  to  telephone  the  butcher, 
she  would  at  once  conjure  up  lifelike  pictures  of  raw  head 
and  bloody  bones,  while  all  the  loathsome  scenes  connected 
with  the  shambles  would  so  crowd  her  vivid  imagination, 
that  she  would  be  at  once  seized  with  nausea  and  vomiting. 

In  my  early  years  of  practice  I  attended  a  primapara, 
whose  husband  was  a  hearty  and  robust  man.  He  ate  a 
good  breakfast,  but  soon  after,  on  being  grieved  by  her 


PSYCHIC    INDIGESTION  285 

pains  and  lamentations,  vomited  the  whole  meal,  nor  could 
he  eat  again  until  she  was  safely  delivered. 

Recently  there  came  under  my  care  for  chronic  indiges- 
tion a  married  lady,  who,  up  to  the  death  of  her  only  infant, 
which  occurred  a  year  before,  "never  knew  that  she  had  a 
stomach,"  to  quote  her  own  words.  Treatment  proved 
unavailing,  until  the  prospects  of  another  offspring  changed 
the  tenor  of  her  melancholy  thoughts,  after  which  she  had 
no  more  indigestion. 

The  stomach  is  keenly  susceptible  to  the  slightest  changes 
in  the  mental  state.  The  mere  sight  of  a  fly  in  the  food  is 
entirely  sufficient  to  cause  many  persons  to  vomit  forth- 
with. The  thought  of  an  emetic  will  produce  nausea  and 
even  active  regurgitation  in  numerous  individuals,  while  the 
cathartic  effect  of  fear  is  well  known. 

That  the  powers  of  digestion  depend  greatly  on  the  state 
of  mind  and  on  the  relish  with  which  food  is  eaten  is  also 
well  known.  On  the  other  hand  perfectly  good  food 
materials  may  become  difficult  or  impossible  of  digestion 
as  the  result  of  learning  something  about  their  mode  of 
preparation.  Many  particular  people  cannot  eat  with 
relish,  or  digest  with  comfort,  butter,  milk,  or  eggs  unless 
they  know  that  they  are  clean  and  fresh.  Walsh  relates  the 
story  of  the  farmer's  wife  who  wanted  to  trade  her  own  but- 
ter for  an  equivalent  amount  made  by  someone  else  because 
she  had  seen  a  mouse  in  the  cream,  and  her  children  could 
not,  therefore,  eat  it.  On  making  the  supposed  trade,  she 
received  back  her  own  butter,  only  in  a  different  crock,  and, 
taking  it  home,  she  cheerfully  ate  it  herself  and  fed  it  to  her 
children. 

That  an  article  may  be  eaten  with  relish  until  its  char- 
acter is  known,  is  illustrated  by  Max  MuUer's  story  of  an 
Englishman,  traveling  in  China.  Fearful  that  he  would  be 
unable  to  obtain  food  that  he  cared  for,  because  of  his  ignor- 
ance of  the  language  of  the  cotmtry,  he  was  rather  surprised 
on  his  first  day's  journey  into  the  interior,  to  be  served  with 
a  stew  made  of  some  kind  of  dark  meat  that  tasted  very  well 


286         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

indeed,  and  with  which  he  was  so  pleased  that  he  asked 
for  a  second  helping.  Just  as  he  was  about  to  eat  the 
second  portion,  he  thought  it  well  to  ask  the  waiter  what 
sort  of  meat  it  was,  as  he  wished  to  be  able  to  obtain  the 
same  kind  at  other  places.  He  thought  that  he  was 
eating  duck,  so,  calling  the  waiter  to  him,  he  said,  pointing 
to  the  dish  of  meat  with  a  questioning  tone,  "Quack, 
quack?"  The  waiter  at  once  shook  his  head  and  said, 
"Bow,  wow,  wow!"  The  Englishman  pushed  away  the 
second  portion,  left  the  table,  and  with  difficulty  retained 
his  meal. 

Custom  and  the  mental  attitude  in  different  parts  of  the 
world  regulate  to  a  marked  extent  the  digestibility  of  food- 
stuffs. Articles  that  are  highly  prized  delicacies  in  some 
countries  are  abhorred  in  others..  Dog  meat,  horse  flesh, 
shark  fins,  etc.,  are  instances  of  this  sort. 

In  Italy  most  visitors  eat  snail  soup  with  relish  before 
they  know  what  it  is.  It  is  said  that  at  Marseilles,  epicures 
occasionally  eat  angle  worms,  finding  them  quite  an  appe- 
tizing dish.  In  all  of  these  things  the  question  of  relish, 
and  peaceful,  easy  digestion  depends  entirely  on  the  attitude 
of  mind.  The  first  men  who  ate  eels  were  looked  on  with 
suspicion  by  their  nieghbors,  while  it  has  been  said  that  the 
man  who  first  swallowed  a  raw  oyster  performed  as  great  a 
feat  as  some  of  our  famous  heroes. 

Some  articles  of  food,  which  excite  disgust  at  first,  if 
continually  eaten,  and  if  the  mind  is  constantly  inhibited 
from  acting  unfavorably  on  the  stomach  while  it  is  being 
eaten  and  digested,  may  eventually  become  valued  and 
prized  viands. 

That  it  may  be  practicable  to  overcome  many  of  the 
prejudices  under  the  stress  of  necessity  and  the  influence  of 
example,  was  well  illustrated  during  the  siege  of  Paris.  The 
Prussians,  though  a  most  particular  people  in  the  matter  of 
their  food,  were  able  to  accommodate  themselves  to  the 
conditions,  and  practically  every  kind  of  animal  was  eaten 
with  relish.     Before  the  siege,  to  most  of  them  it  would 


IDIOSYNCRASIES  287 

have  seemed  impossible  that  they  should  view  with  com- 
placency the  dishes  which  were  afterward  so  appetizing. 
At  the  beginning  there  was  an  effort  to  conceal  the  eating 
of  rats,  mice,  cats  and  dogs  under  various  names,  and  by 
modes  of  preparation  intended  to  disguise  their  identity. 
It  was  not  long,  however,  before  there  was  an  end  of  this 
pretense,  and  every  animal  was  eaten  under  its  own  name, 
and  gladly. 

Idiosyncrasies. — That  these  do  exist,  and  in  some  people 
rest  on  a  real  physiologic  basis  is  an  undoubted  fact.  There 
are  many  instances  on  record  where  the  ingestion  of  certain 
food-stuffs,  wholesome  and  nutritious  in  themselves,  would 
set  up  urticaria,  vomiting,  diarrhea,  headache,  or  other 
definite  symptoms,  even  if  the  patient  were  unaware  of  the 
presence  of  these  food-stuffs  in  the  bill  of  fare. 

I  have  seen  more  than  one  person,  on  whom  eggs  acted 
as  a  violent  gastrointestinal  irritant;  others  who  could  not 
eat  butter  without  diarrhea;  some  with  whom  milk  really 
disagreed;  and  many  who  could  not  eat  shell-fish  with  safety. 
I  may  correctly  affirm,  however,  that  these  idiosyncrasies 
are  much  more  rare  than  are  supposed.  In  the  vast 
majority  of  these  individuals  the  idiosyncrasy  is  only  a 
mental  attitude  which  acts  so  positively  in  opposition  to 
the  digestion  of  these  feared  articles,  that  the  proper 
digestive  juices  are  inhibited,  motility  is  impeded,  and 
digestive  disturbances  of  more  or  less  grave  import  follow 
their  ingestion. 

This  fear  of,  and  mental  antipathy  to  special  articles  of 
food  is  denominated  sitophobia,  and  this  most  important 
psychic  manifestation  is  worthy  of  the  most  thoughtful 
study  by  every  earnest  worker  in  the  field  of  dietetics. 

Sitophobia. — This  term,  signifying  a  morbid  fear  of 
food  is  of  somewhat  recent  use,  though  the  condition  is  an 
ancient  one,  being  the  exhibition  of  those  peculiar  "dis- 
tempers," in  which  certain  foods  were  repugnant  or  even 
dangerous,  and  in  which  the  horror  of  some  highly  esteemed 
viands  was  ascribed  to  demoniac  possession. 


288        PSYCHOTHERAPY  IN   GASTROINTESTINAL  DISEASES 

In  the  same  class  of  phobias  as  comes  the  fear  of  high 
places,  or  open  places,  or  closed  rooms,  etc.,  may  be  placed 
sitophobia,  with  its  fixed  and  often  apparently  causeless 
antipathy  to  some  foods.  Frequently  this  phobia  is  con- 
fined to  a  single  viand.  Probably  every  physician  who 
reads  this  will  call  to  mind  a  patient,  who  fancies  that  some 
ordinarily  harmless  article  contains  for  her  or  him  a  dread- 
ful potentiality  for  evil.  The  patient  will  explain  that 
since  a  child  this  article  has  been  tabood,  and  to  eat  it 
would  invite  direful  consequences.  Close  inquiry  may  elicit 
the  admission  that  the  aforesaid  article  has  not  been  eaten 
since  childhood,  perhaps  never,  but  it  had  disagreed  with 
him  at  the  time,  or  had  disagreed  with  some  member  of 
his  family,  and  the  inference  has  been  drawn  that  it 
would  necessarily  act  as  a  poison  to  this  particular  indi- 
vidual. 

I  have  in  mind  a  traveling  salesman,  who  is  morbidly 
afraid  of  butter  or  any  dish  prepared  from  it.  The  sight 
of  butter  on  the  table  before  him  fills  his  mind  with  fearful 
forebodings,  while  much  of  his  pocket  money  is  spent  in 
tips  to  waiters  and  cooks  that  nothing  may  be  served  him 
containing  this  evil  agent. 

A  sitophobia  may  arise  from  some  disgusting  incident  in 
the  past  connected  with  a  particular  dish,  as  the  following 
will  illustrate:  Some  years  ago  a  gentleman  went  fishing 
in  a  Southern  river  at  a  time  when  the  waters  were  high. 
Finding  a  promising  eddy  in  the  stream,  he  began  fishing, 
and  soon  caught  an  amazing  number  of  large  catfish. 
Two  days  later  he  decided  to  again  fish  there,  but  when  he 
arrived,  the  now  fallen  waters  disclosed  the  carcass  of  a 
cow,  entangled  in  the  debris  collected  by  the  eddy,  and  he 
quickly  understood  why  he  had  caught  so  many  fish. 
From  that  day  he  has  never  been  able  to  eat  catfish,  nor  can 
he  enjoy  a  meal  when  this  fish  is  on  the  table. 

Another  etiologic  factor  in  producing  a  sitophobia  is  a 
disagreeable  or  painful  personal  experience  with  some  food 
or  food  product,   as  the  following  illustrates:  A  lady  of 


SITOPHOBIA  289 

mature  years  informed  me  that  when  a  small  girl  she  was 
inordinately  fond  of  apple  dumplings,  thinking  she  could 
never  get  enough.  On  one  occasion,  however,  the  cook 
made  a  special  baking  of  this  coveted  delicacy  so  as  to  per- 
mit this  youthful  epicurean  to  have  her  fill.  The  result 
was  a  severe  attack  of  indigestion,  leaving  in  its  wake  a 
phobia  for  apple  dumpling  that  time  has  not  erased. 

Another  fruitful  cause  of  sitophobia  lies  in  the  writings 
of  self-appointed  health  teachers  who,  with  lurid  phihppics, 
couched  in  attractive  language,  bolstered  up  specious  argu- 
ments, and  hurled  at  some  of  our  most  wholesome  articles 
of  food,  create  injurious  dietic  fears  and  fads. 

Many  of  the  cults  and  isms,  and  schools  of  "new  thought," 
by  their  fallacious  doctrines  cultivate  in  the  minds  of  their 
devotees  genuine  phobias  for  elements  and  articles  of  food 
that  are  important  to  bodily  strength  and  welfare. 

Suggestions  of  Indigestion. — As  brought  forward  forcibly 
by  Walsh,  an  unfortunate  state  of  the  public  mind  with 
regard  to  indigestion  in  general  has  been  cultivated  by  many 
publications  on  the  subject.  People  dread  its  occurrence, 
and  fear  that  the  first  sign  of  discomfort  in  their  gastric 
region  is  the  signal  of  the  beginning  of  a  progressive  affec- 
tion. They  fear  the  worst,  and  the  consequence  is  a  reac- 
tion quite  out  of  proportion  to  the  gravity  of  the  ailment. 
So  much  has  been  said  and  written  concerning  mistakes  in 
diet,  that  just  as  soon  as  they  feel,  or  rather  think  they  feel, 
the  first  symptom  of  beginning  dyspepsia,  they  begin  to 
study  how  to  modify  their  diet  so  as  to  check  its  progress. 
They  first  begin  to  eliminate  various  supposedly  indigestible 
foods,  and  usually  among  the  first  are  the  fats  and  some  of 
the  starchy  vegetables.  These  people  have  generally 
heard  also  that  it  is  harmful  to  drink  fluid  with  meals,  so 
they  eliminate  a  great  part  of  their  wonted  allowance  of 
fluid.  Leaving  out  of  their  dietary  one  article  after  another, 
they  seldom  realize  the  expediency  or  necessity  of  replacing 
the  eliminated  foods  with  others  so  that  the  caloric  balance 
may  be  kept  up.  "  Consequently,  many  of  these  self-made 
19 


290         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

invalids  suffer  for  long  periods  of  time,  not  so  much  from 
faulty  digestion  as  from  chronic  starvation. 

I  have  observed,  in  a  surprising  number  of  instances, 
weak  and  emaciated  individuals,  who  had  been  on  a  rigor- 
ous diet  for  months  and  years,  in  whom  the  original  disorder 
for  which  the  diet  was  instituted  had  long  since  disappeared, 
but  who,  with  a  tenacity  worthy  of  a  better  cause,  would 
cling  with  mistaken  fortitude  to  a  dietary  totally  inadequate 
to  the  legimitate  caloric  requirements,  and  which  would 
inevitably  bring  them  to  a  state  of  physical  bankruptcy. 

Recently  there  came  under  my  care  a  woman  of  fifty- 
eight  years,  who  had  been  on  a  diet  of  toast  and  tea  for 
fifteen  years.  The  physician  who  originally  put  her  on  this 
was  long  since  dead,  and  she  adhered  to  this  unsatisfying 
and  monotonous  diet  only  because  she  feared  that  any  other 
food  would  give  her  indigestion.  She  was  thin,  tremulous, 
emotional,  and  the  constant  gnawing  pangs  of  hunger,  which 
she  misinterpreted  as  the  pains  of  disease,  were  ever  with 
her. 

An  examination  disclosed  a  sufficiency  of  gastric  juices  in 
her  stomach,  while  no  diagnosis  of  an  organic  malady  could 
be  made. 

Much  persuasion  and  many  reassurances  were  needed  to 
get  her  back  on  a  well-balanced  and  satisfying  diet,  but  this 
was  finally  accomplished.  She  gained  28  pounds  in  three 
months,  and  at  present  seems  in  good  health. 

Another  point  to  be  considered  is  the  influence  of  a  diet 
on  the  mind  of  a  susceptible  patient.  Everything  con- 
nected with  a  particular  or  restricted  diet  tends  to  center 
the  thoughts  on  the  stomach,  and  the  patient  finds  it  ever 
present  in  his  waking  meditations.  It  tends  to  permeate 
his  daily  conversation,  and  he  finally  becomes  almost  if  not 
quite  obsessed  on  the  theme  of  his  digestion.  Can  we 
wonder  that  such  people  suffer  from  a  psychic  form  of 
indigestion  ? 

A  case  is  related  by  Dr.  Sadler  of  a  woman  who  had  an 
attack"  of  "acute  indigestion"  some  eight  years  ago,  and 


PSYCHOTHERAPY  29 1 

ever  since  had  been  a  constant  sufferer  from  a  most  obsti- 
nate and  refractory  form  of  indigestion,  which  had  with- 
stood all  efforts  toward  a  cure.  Her  mind  was  ever  on  her 
stomach,  and  she  could  talk  of  but  little  else.  A  careful 
chemical  examination  of  the  contents  of  her  stomach  failed 
to  disclose  anything  radically  wrong;  to  say  the  least,  not 
enough  to  account  for  her  symptoms. 

It  was  not  considered  best  to  present  the  full  facts  to  her 
at  once.  She  had  nursed  her  complaint  entirely  too  long 
and  too  lovingly  ever  to  be  persuaded  that  her  indigestion 
actually  existed  primarily  in  her  mind,  and  that  her  stomach 
disorder  and  distress  were  but  the  reproduction  of  her  own 
mental  disorder.  In  other  words,  she  was  entirely  too 
self-centered  to  be  convinced  that  her  difficulty  was  of  a 
psychic  nature. 

The  following  plan  was  adopted:  She  was  told  that  an 
exact  diagnosis  of  her  stomach  trouble  had  been  made ;  that 
the  laboratory  findings  were  explicit  and  positive;  that  at 
last  we  knew  the  precise  condition  of  her  stomach,  and  that 
we  were  also  able,  as  far  as  physicians  ever  are,  to  promise 
her  that  she  would  make  a  speedy  and  complete  recov- 
ery under  the  proper  treatment  and  diet,  and  that,  in 
all  probability,  she  would  be  entirely  well  within  thirty 
days. 

She  was  utterly  dumfounded  at  this  promise,  and  replied 
that  it  was  too  good  to  believe — too  much  to  expect,  after  all 
the  years  she  had  suffered,  whereupon,  we  replied  that 
absolute  trust — implicit  faith — was  required  on  the  part  of 
the  patient  in  the  treatment  of  all  such  forms  of  stomach 
disorder;  and  that  if  she  continued  to  harbor  distrust,  it 
would  give  rise  to  such  a  nervous  state  as  would  effectively 
counteract  the  curative  powers  of  our  diet  and  other  treat- 
ment. The  latter  consisted  of  the  following:  A  general 
course  of  baths,  massage,  and  electricity  calculated  to  rest 
and  soothe  both  mind  and  body,  together  with  a  graduated 
scheme  of  diet,  arranged  so  as  gradually  to  restore  all  the 
numerous  wholesome  foods  which  she  had  discarded  on  the 


292         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

supposition  that  they  did  not  agree  with  her,  or  that  they 
aggravated  her  indigestion. 

Day  by  day  she  had  restored  to  her  diet  those  supposedly 
harmful  articles  of  food,  while  day  by  day  we  assured  her 
that  they  would  not  disagree  with  her ;  and  day  by  day  she 
ate  the  prescribed  diet,  and  it  really  did  not  disagree.  At 
the  end  of  a  week,  she  began  to  gain  in  weight  and  to  gain 
strength  and  courage.  She  actually  got  the  hope  in  her 
mind  that  she  was  going  to  get  well.  Her  appetite  began  to 
improve;  she  began  to  smile  and  talk  about  her  wonderful 
recovery,  saying  she  believed  the  secret  of  her  case  had  at 
last  been  discovered,  and  that  she  was  assuredly  going  to 
get  well.  Within  four  weeks  the  battle  was  practically 
won,  her  long  struggle  with  "nervous  dyspepsia"  was 
over,  and  she  has  ever  since  rejoiced  in  the  blessing  of 
good  health  and  a  sound  digestion. 

The  psychic  influences  concerned  in  the  production  of 
"appetite  juices"  have  been  discussed,  but  the  power  of 
these  influences  over  the  motor  functions  of  the  stomach  is 
of  the  utmost  importance.  With  the  aid  of  the  X-ray  the 
movements  of  the  digestive  organs  have  been  plainly  dis- 
closed, and  the  effect  of  the  emotions  over  the  musculature 
of  the  stomach  and  intestines  has  been  graphically  demon- 
strated. The  rays  have  further  proved  that  faith  and 
courage — the  normal  mental  state — favor  strong  and  regu- 
lar contractions  of  the  stomach  muscles,  with  rhythmic 
contraction  and  relaxation  of  the  pyloric  outlet,  while  fear, 
or  anger,  or  disgust  either  weaken  or  inhibit  these  muscular 
phenomena,  exercising  a  corresponding  hindrance  to  proper 
and  comfortable  digestion.  This,  being  repeated  suffi- 
ciently often,  can  interfere  so  seriously  with  the  normal 
digestion,  that  actual  disease  may  be  started,  and  the  foun- 
dation laid  for  later  organic  changes. 

A  number  of  years  ago  I  had  the  opportunity  of  witness- 
ing one  of  the  first  of  these  experiments  which  were  so 
epoch-making.  A  cat  was  fed,  and  while  quietly  digesting 
the  meal,  was  gently  stroked  until  she  began  to  purr.     A 


CONSTIPATION  293 

fluoroscopic  inspection  showed  her  stomach  contracting 
and  emptying  itself  with  regularity,  while  the  peristaltic 
waves  of  her  intestines  could  be  distinctly  seen.  Her  tail 
was  then  pinched  until  she  became  angry,  and  at  once  the 
whole  stomach  and  intestinal  movement  ceased,  nor  was 
it  again  renewed  until  she  was  in  a  good  humor  once  more. 
This  inaction  may  last  for  half  an  hour  or  more,  and  in 
extreme  anger  may  extend  to  reversed  peristalsis  or  emesis, 
as  has  been  noted  in  some  persons  who  vomit  when  vio- 
lently angry. 

In  view  of  these  scientific  experiments  and  disclosures 
respecting  the  mental  influences  which  are  able  to  hasten, 
retard,  or  inhibit  digestive  activity  and  muscular  work 
of  the  stomach  and  intestines,  we  should  be  better  able  to 
understand  how  so  many  downcast,  complaining,  and  sordid 
people  are  continual  sufferers  from  some  form  of  digestive 
discomfort.  Fully  as  much,  too,  are  disorders  of  the  diges- 
tive tract  brought  about  by  ill  temper,  anger,  and  dis- 
satisfaction with  one's  station  in  life.  The  chronic  grumb- 
ler and  fault-finder,  the  overparticular  person,  who  will  not 
eat  with  equanimity  unless  the  food  is  prepared  exactly  to 
suit  him,  is  much  more  prone  to  dyspepsia  than  the  cheery 
optimist,  who  looks  at  the  bright  side,  who  makes  allow- 
ances for  small  shortcomings  in  the  meals  or  in  those  who 
prepare  them,  and  who  can  rise  superior  to  the  little,  nag- 
ging worries  of  every- day  life. 

Even  where  the  progress  of  digestion  is  not  completely 
stopped,  unfavorable  mental  states  may  retard  and  render 
it  difficult  all  through  the  digestive  period. 

Constipation. — Analogous  to  Pavlov's  ingenious  experi- 
ments, with  regard  to  the  influence  of  the  emotions  over 
the  digestive  secretions  in  the  stomach,  are  Kronecker's 
experiments  at  Berne  upon  the  motor  functions  of  the  in- 
testinal tract.  Pavlov  showed  by  "sham  meals"  in  which 
a  dog  was  fed,  while  the  food  escaped  through  a  fistula 
without  entering  the  stomach,  that  the  juices  fiowed  from 
the  gastric  glands  practically  as  freely  as  if  the  food  had 


294         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

really  reached  its  proper  destination.  He  also  demon- 
strated that  the  appetite  depended,  not  on  physical  con- 
ditions so  much  as  on  the  mental  state  of  the  animal  and 
its  desire  for  a  particular  kind  of  food. 

Kronecker,  by  isolating  a  loop  of  the  intestine  in  which  a 
metal  ball  was  placed,  showed  that  it  was  possible  to 
modify  peristalsis  very  materially  by  affecting  the  psychic 
condition  of  the  animal.  There  was  a  distinct  difference 
in  the  movements  of  the  intestines,  in  the  passage  of  a 
metal  ball,  when  the  animal  was  called,  and  expected  to  go 
for  a  walk  with  its  master,  and  when  it  was  threatened 
with  punishment,  or  scolded.  In  even  the  more  intelligent 
animals,  the  emotions  play  a  very  subordinate  role  in  stimu- 
lation and  inhibition  compared  to  that  exercised  by  man's 
higher  nervous  system,  since  in  the  latter  the  psychic 
function  of  the  organism  is  so  much  more  developed  than 
in  the  animal.  The  condition  of  the  human  mind  in  its 
possibilities  of  unfavorable  influence  over  the  intestinal 
motility,  is,  therefore,  extremely  potent. 

The  more  we  investigate  the  actual  power  of  the  mind 
even  over  so  material  a  function  as  intestinal  peristalsis, 
the  more  are  we  convinced  of  the  necessity  of  a  properly 
disposed  mental  attitude  toward  intestinal  evacuation, 
if  it  is  to  be  accomplished  with  regularity  and  without 
disturbance. 

The  bowels  are  markedly  under  the  influence  of  the 
sub-conscious  flersonality  of  every  individual,  and  respond 
readily  to  autosuggestion  as  well  as  suggestion  from  outside 
sources.  Boris  Sidis  tells  the  story  of  a  man  who  used  to 
have  a  brief  siege  of  diarrhea  at  every  new  moon,  as  the 
result  of  his  memory,  acting  unconsciously,  reminding  him  of 
his  mother's  habit  of  giving  him  a  purgative  about  that  time. 

The  oft-told  joke  among  the  laity  about  "bread  pills" 
and  their  cathartic  effect  has  its  foundation  in  fact,  as  is 
shown  by  the  following  which  came  under  my  observation 
a  number  of  years  ago :  A  planter  in  a  Southern  state,  who 
came  in  contact  with  a  large  number  of  negro  farm  laborers 


AUTOSUGGESTION  295 

was  continually  annoyed  by  their  requests  for  cathartic 
pills.  A  druggist  in  a  neighboring  town  had  a  large  glass 
globe  containing  probably  a  gallon  of  immense  but  inert 
pills,  which  were  sent  by  a  manufacturer  of  pills  simply  as 
an  advertisement.  The  druggist  gave  these  to  the  planter, 
who  in  turn  gave  them  to  the  laborers  when  they  wished 
cathartic  pills.  To  his  surprise,  in  nearly  every  instance 
the  pills  moved  the  bowels  profusely,  and  the  negroes 
esteemed  them  as  a  new  pill  of  wonderful  efficacy. 

As  mental  influence  and  autosuggestion  can  readily  set 
up  increased  peristalsis  and  diarrhea,  so  can  they  interfere 
with  the  regular  movement  of  the  bowels.  Markedly  so 
are  the  evacuations  regulated  by  habit,  and  the  presence  of 
feces  in  the  rectum  serves  as  a  gentle  stimulus.  As  we 
have  an  appetite  for  dinner  at  the  appointed  time,  though 
not  exhausted  by  labor;  and  as  our  eyeUds  grow  heavy  at 
the  time  we  habitually  retire  to  bed,  even  though  the  day 
has  not  been  strenuous;  and,  as  when  our  meal-time  has 
been  passed  without  eating,  we  lose  our  appetite,  or  our 
bedtime  has  been  passed  without  retiring,  we  lose  our  ability 
to  fall  asleep  promptly,  so  it  is  with  the  function  of  defeca- 
tion. A  change  in  regular  habits,  or  a  neglect  to  heed  the 
sub-conscious  call  to  evacuate  the  bowels  will  tend  to  the 
constipated  habit. 

The  neglect  to  heed  the  call  of  Nature  until  necessity 
forces  it,  is  a  common  fault  with  young  girls,,  and  is  the 
prime  cause  of  a  constipation  which  often  follows  them 
through  life.  Others  bring  constipation  upon  themselves 
by  a  poor  choice  of  the  time  devoted  to  this  function.  It 
might  be  at  an  hour  when  duties  were  pressing,  and 
sufficient  time  could  not  be  spared  to  obey  the  call.  The 
next  day  perhaps  the  need  was  felt  again,  and  again  re- 
sisted. Later,  the  intestines,  whose  calls  and  warnings 
were  unheeded  would  fail  to  send  the  call,  the  sub-conscious 
personality  would  fail  to  sound  its  "still,  small  voice,"  the 
bonds  of  habit  would  be  broken,  and  the  unfortunate 
bonds  of  constipation  established. 


296         PSYCHOTHERAPY   IN   GASTROINTESTINAL   DISEASES 

A  regular  and  convenient  time  for  going  to  the  toilet 
should  be  chosen,  and  the  individual  should  go  and  make 
a  determined  effort. 

Dubois  has  grouped  together  several  reasons  why  a 
rather  early  morning  hour  is  advisable.  To  quote  him, 
"I  chose  the  morning  because  it  is  the  time  when  we  are 
freer  to  attend  to  these  hygienic  cares,  and  because  nor- 
mally, during  the  long  night,  the  slow  movement  of  the 
intestines  has  brought  to  the  rectum  all  the  waste  products 
of  our  food.  There  is,  therefore,  in  the  morning  an  early 
invitation  to  go  to  the  toilet  which  arises  from  the  very 
accumulation  of  material." 

The  act  of  waking  in  itself  constitutes  a  second  stimulus. 
I  know  a  number  of  people  for  whom  the  awakening  of 
peristaltic  movements  follows  the  awaking  of  their  per- 
son. It  is  inconvenient,  for  they  are  obliged  to  imme- 
diately obey,  and  to  jump  out  of  the  bed  in  which  they 
were  so  comfortable." 

"The  act  of  getting  up  with  the  movements  of  the  body 
which  are  caused  by  one's  toilet,  the  movement  of  putting 
on  one's  stockings  and  of  getting  into  one's  trousers  have  an 
effect  like  massage,  which  is  so  efficacious  that  I  have  had 
some  people  complain  that  they  cannot  forego  the  need  after 
having  laced  their  first  shoe." 

"Here  are  three  invitations  which  follow  one  after  the 
other,  and  which  become  habitual,  especially  if  the  time  for 
rising  follows  the  waking  at  a  fixed  time:  To  take  a 
glass  of  cold  water  on  getting  up  is  a  measure  which  has 
often  been  recommended.  Entering  the  stomach  which 
has  been  empty  the  evening  before,  the  water  stimulates 
the  movement  of  the  stomach,  and  the  contraction  extends 
throughout  the  intestine;  this  is  the  fourth  stimulus.  If 
the  patient  has  noticed  that  warm  or  hot'  water  succeeds 
better,  I  do  not  insist  on  the  cold  water.  If  the  patient  is 
a  smoker  who  has  felt  the  good  effects  of  a  cigarette,  I 
permit  him  to  use  it." 

"The  eating  of  breakfast,  especially  if  it  is  quite  hearty, 


PSYCHIC   INFLUENCES  297 

and  consists  in  part  of  bread  and  butter,  particularly  whole 
wheat  bread  or  graham  bread,  also  stimulates  peristaltic 
movements.  Honey  may  be  a  useful  adjunct  when  a 
person  can  take  it." 

A  short  time  after  breakfast  is  with  many  people  the  most 
convenient  time  to  go  to  stool,  for  the  actual  peristalsis 
started  by  the  morning  meal,  is  easily  extended  throughout 
the  entire  intestinal  canal  by  proper  effort  and  mental 
encouragement.  The  habit  many  people  have  formed  of 
taking  with  them  to  the  toilet  a  newspaper  or  book,  is  a 
good  one,  for  it  permits  of  a  sufficiency  of  time  to  be  spent 
in  the  effort,  while  the  quiet  placid  frame  of  mind,  aided  by 
the  reading  allows  the  sub-conscious  forces  to  exercise  their 
important  functions  in  inaugurating  and  promoting  the  act 
of  defecation. 

I  may  say  that  by  far  the  most  important  factor  in  the 
psychic  management  is  to  impress  on  the  patient  the  ne- 
cessity of  absolute  regularity,  to  the  minute,  if  possible,  in 
going  to  the  toilet,  and  next  that  he  should  remain  there 
with  his  mind  fixed  upon  the  function,  and  with  every 
bodily  effort  brought  into  play  toward  that  end.  If,  after 
a  prolonged  effort,  he  fails,  it  may  be  best  not  to  go  again 
that  day,  but,  as  Dubois  expresses  it,  "Say  to  your  intes- 
tines :  you  would  not  move  at  the  proper  time ;  now  you 
can  wait  till  to-morrow."  In  all  probability  the  second 
attempt  at  the  same  time  the  following  day  will  succeed. 

Occasionally  it  may  be  advisable  to  have  accessible  a 
small  piece  of  soap,  or  a  glycerine  suppository,  or  even  a 
syringe  with  warm  water,  so  a  small  enema  may  be  taken. 
These  may  be  employed  to  start  the  act  of  defecation,  but 
should  be  kept  as  a  last  resort,  and  seldom  employed.  If 
the  proper  amount  of  care  as  to  these  precautions,  coupled 
with  perseverance  is  entered  into,  plus  proper  diet  and 
hygiene,  the  vast  majority  of  cases  of  constipation  can  be 
cured  without  the  administration  of  any  drugs.  This  I  say, 
not  as  a  psycho-therapeutic  enthusiast,  but  as  one  who  en- 
deavors to  use  every  method  included  in  rational  therapy. 


298         PSYCHOTHERAPY   IN   GASTROINTESTINAL   DISEASES 

Intestinal  Autointoxication. — This  is  an  overworked 
term,  not  only  among  the  medical  profession,  but  the  laity 
as  well.  Much  misleading  literature  on  this  subject  has 
been  written  by  pseudo-health-teachers,  who  in  picturesque 
language  have  described  the  dreadful  condition  likely  to 
befall  the  unfortunate  who  is  afflicted  with  this  awful  but 
indefinite  condition. 

The  idea  had  often  occurred,  and  had  been  expressed 
vaguely  in  the  older  medical  literature,  but  it  gathered  a 
new  impetus  when  there  came  into  vogue  that  high-sounding 
Greek  word  copremia,  literally  meaning  "  excrementitious- 
substances-in-the-blood,"  in  the  early  part  of  the  nin- 
teenth  century.  This  strong  suggestion  was  immensely 
strengthened  by  Bouchard,  a  generation  later,  whose  con- 
vincingly written  work  demonstrated  how  much  toxic 
material  was  reabsorbed  from  the  intestines,  as  an  experi- 
ment using  the  urine  for  injections  into  animals.  His 
experiments  were  open  to  many  objections,  and  many  of  his 
conclusions  are  now  discredited. 

Arthur  Hertz  in  his  recent  book,  "Constipation  and 
Allied  Intestinal  Disorders,"  reviews  the  whole  subject,  and 
shows  that  we  are  without  any  definite  conclusive  evidence 
for  what  has  been  talked  and  written  about  so  much. 

Many  persons  who  have  read  much,  and  are  deeply 
interested  in  the  subject  of  autointoxication,  become  sure 
that  the  slightest  delay  in  intestinal  evacuation  may  be 
serious,  or  that  it  may  profoundly  disturb  their  physical 
economy.  If,  for  any  reason,  they  fail  to  have  a  movement 
at  the  regular  time,  they  begin  to  worry,  and  in  a  few 
hours  they  begin  to  search  their  feelings  for  the  dread 
symptoms  of  autointoxication.  After  two  or  three  more 
hours  they  begin  to  have  a  headache,  then,  perhaps,  they 
feel  so  badly  that  they  have  to  give  up  work  for  the  day. 
Further  worry  will  cause  their  sleep  to  be  delayed  or 
troubled,  and  they  wake  unrefreshed,  while  practically, 
if  not  entirely,  all  of  these  symptoms  are  due  to  auto- 
suggestion. 


INTESTINAL    AUTOINTOXICATION  299 

Regular  evacuations  of  the  bowels  are  necessary,  and  full 
and  free  emptying  of  the  large  intestine  at  frequent  in- 
tervals is  conducive  to  health,  comfort  and  longevity. 
This  is  admitted.  While  it  is  the  custom  of  most  civilized 
human  beings  after  infancy  to  have  one  movement  of  the 
bowels  daily,  this  is  not  a  hard  and  fast  rule.  Many  there 
are,  who  normally  evacuate  their  bowels  twice  daily, 
and  would  suffer  some  inconvenience  if  this  were  interfered 
with.  Many  others  find  that  an  evacuation  every  other 
day  is  entirely  sufficient,  and  enjoy  good  health  under  this 
habit.  There  are  exceptional  instances  of  individuals  who 
have  habitually  emptied  their  bowels  at  intervals  of  several 
days,  or  weeks,  or  even  months,  and  have  lived  long  and 
active  lives,  seeming,  at  least,  to  enjoy  a  fair  amount  of 
health, 

I  have  in  mind  a  man,  now  over  fifty  years  of  age,  who 
states  that  never  since  a  child  has  he  had  a  fecal  movement 
more  often  than  once  every  ten  days — sometimes  two  weeks. 
He  is  now  an  active  and  successful  business  man,  has  had 
no  severe  illness  in  his  past  life,  and  his  present  appearance 
promises  many  active  years  to  come. 

■  Walsh  relates  the  case  of  a  French  army  officer,  who,  from 
his  earliest  years,  did  not  have  regular  movements  of  the 
bowels,  but  secured  evacuation  of  them  by  artificial  aid 
once  every  two  months  or  more.  He  lived  to  the  age  of 
past  fifty,  dying  from  an  intercurrent  disease  not  connected 
with  his  intestinal  condition,  having  in  the  meanwhile 
enjoyed  good  health.  He  was  able  to  accomplish  his 
duties  as  an  officer  without  any  special  allowances,  and 
was  on  the  sick  list  much  less  than  many  brother  officers, 
whose  intestinal  condition  left  nothing  to  be  desired.  This 
man  succeeded  in  doing  his  life  work  without  his  condi- 
tion being  known  by  others  to  any  extent,  and  it  was  only 
inconvenience  and  not  serious  illness  that  he  suffered  from. 
After  his  death,  it  was  found  that  certain  folds  of  the  lower 
bowel  were  so  large  as  to  meet  across  its  lumen,  making 
shelves  and  pouches  in  which  the  fecal  material  accumu- 


300         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

lated,  preventing  the  movement  of  the  bowel  contents 
above. 

In  the  Orient,  it  is  reported  that  many  .especially  of  the 
better  class,  do  not  expect  to  have  movements  of  their 
bowels  every  day.  Some  of  them  do  not  encourage  this 
function  more  often  than  once  a  week,  or  even  more  seldom. 
As  their  diet  is  more  largely  vegetable  than  ours,  this  is 
all  the  more  surprising.  The  average  life  of  such  people 
does  not  seem  to  be  much  below  the  Occidentals,  and  the 
difference  is  probably  accounted  for  to  a  great  extent  by 
other  hygienic  practices,  rather  than  this  failure  to  have 
regular  movements.  In  the  meantime,  they  do  not  suffer 
any  particular  inconvenience,  and  seem  as  free  from  the 
ordinary  aches  and  pains  of  life  as  do  the  people  of  the 
West. 

It  appears  that  if  such  a  custom  is  established  in  the 
early  life  of  an  individual,  that  Nature  becomes  able,  by 
some  power  of  compensation,  to  either  overcome  or  neu- 
tralize the  toxins  which  would  tend  to  be  absorbed  from 
the  large  intestine. 

Our  patients  should  be  admonished  of  the  great  need  of 
regular  daily  evacuations  of  the  bowels,  and  should  be 
urged  in  the  interest  of  their  health  to  pursue  this  custom, 
so  far  as  possible,  with  clocklike  punctuality.  On  the 
other  hand,  they  should  not  be  permitted  to  become 
abject  slaves  to  the  fear  of  intestinal  autointoxication,  but 
should  be  taught  some  of  the  lessons  I  have  endeavored 
to  promulgate. 

Gastric  and  Intestinal  Flatulence. — Many  of  the  patients 
who  come  to  the  physician  seeking  relief  from  supposed 
heart  disease,  are  in  reality  suffering  from  the  primary  or 
secondary  effects  of  gastric  flatulence.  In  some  the  heart 
tolerates  considerable  upward  pressure  on  the  diaphragm 
from  a  distended  stomach.  In  some  neurotic  individuals, 
however,  distention  of  the  stomach,  or  any  appreciable 
collection  of  flatus,  either  disturbs  the  heart's  action  or 
greatly  upsets  the  patient's  mental  equilibrium. 


AEROPHAGIA  301 

The  presence  of  gas  in  the  stomach  is  a  bane  to  many. 
It  cannot  be  accounted  for  by  fermentation  of  food  prod- 
ucts in  the  stomach,  for  it  is  frequently  produced  in  the 
presence  of  a  sufficiency  of  free  hydrochloric  acid,  and  where 
no  fermentation  can  exist.  Besides  no  fermentation  could 
produce  the  immense  quantities  which  are  so  explosively 
eructated  by  these  nervous  people. 

One  lady  informed  me  that  she  counted  the  number  of 
eructations  after  a  light  meal  of  toast  and  tea,  and  that  they 
numbered  one  hundred  and  forty-one. 

When  uncomfortable  gastric  flatulence  occurs  in  neurotic 
people,  when  the  eructations  are  frequent,  explosive,  and 
without  much  taste  or  odor,  the  trouble  may  generally 
be  ascribed  to  aerciphagia,  or  unconsciously  swallowed 
atmospheric  air. 

Bouvert  explains  the  modus  operandi  by  which  this 
bizarre  phenomenon  is  produced  as  due  to  clonic  spasm  of 
the  pharynx,  while  Ewald  contends  that  it  is  produced  by 
contracting  muscles  of  the  neck.  Storck  agrees  with 
Ewald,  and  cites  some  points  concerning  the  differential 
diagnosis  of  aerophagia  from  gastrectasis.  In  the  latter 
condition  the  eructations  are  gaseous  in  character,  are  of  a 
decided  odor,  and  contain  sulphurated  hydrogen  and 
marsh  gas.  Aerophagia  should  also  be  distinguished  from 
the  burning  eructations  accompanying  hyperchlorhydria, 
as  well  as  real  fermentation  sometimes  occurring  in  achylic 
stomachs. 

Vanderhoof  records  a  case  of  aerophagia  in  a  hysterical 
subject,  where  she  belched  over  five  thousand  times  in 
twenty-four  hours,  and  the  amount  of  air  eructated  being 
measured,  was  found  to  exceed  200  liters.  It  is  evident  that 
this  quantity  of  air  is  many  times  in  excess  of  that  which 
could  be  produced  by  any  conceivable  process  of  fermenta- 
tion; and  furthermore  this  air  has  been  collected  and 
analyzed  by  several  investigators,  who  have  shown  that 
it  approaches  in  composition  atmospheric  air,  being  com- 
posed almost  entirely  of  nitrogen  and  oxygen,   with  an 


302         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

admixture  of  but  a  small  quantity  of  carbon  dioxid,  the 
latter  being  derived  from  the  decomposition  of  the  carbon- 
ates in  the  food  or  the  alkaline  saliva. 

Carminatives  will  generally  be  needed  to  some  extent  in 
the  management  of  these  cases,  but  the  main  point  is  to 
convince  the  patient  that  if  composure  is  exercised,  and 
quietude  is  sought,  less  air  will  be  swallowed,  and  most  of 
that  present  will  be  unconsciously  absorbed  and  expired 
with  the  breath. 

Some  years  ago  there  consulted  me  a  middle-aged  maiden 
lady  of  high  intelligence,  who  held  an  important  executive 
position  in  a  large  female  college.  She  complained  bitterly 
of  a  flatulent  condition  of  her  stomach,  which  would  gener- 
ally come  on  after  supper,  especially  if  the  day  had  been  a 
busy  or  trying  one.  When  she  felt  this  gas,  she  would 
walk  the  floor  and  indulge  in  various  gymnastic  exercises, 
feeling  that  she  must  get  rid  of  it  before  she  could  safely 
retire.  Upon  my  explanation  of  the  real  condition,  with 
the  assurance  that,  if  she  would  sit  quietly  and  placidly, 
the  gas  would  either  pass  into  the  intestine  or  be  absorbed, 
she  took  my  advice,  and  soon  she  found  to  her  surprise 
that  there  was  practically  no  gas  to  expel.  In  her  case, 
she  was  swallowing  the  air  as  fast,  or  faster  than  she  could 
expel  it,  and  in  the  meanwhile  provoking  her  nervous 
system  almost  into  a  frenzy. 

Personally  I  believe  that  this  condition  is  always  associ- 
ated with  a  certain  lack  of  tone  in  the  gastric  musculature, 
and  that  in  individuals  with  neurotic  stigmata  it  is  most 
probable  that  certain  states  of  nervousness  produce  an 
inhibition  of  the  nerves  controlling  this  normal  tone. 
Certain  emotions  or  reflex  agencies  bring  about  a  loss  of 
tone  in  the  walls  of  the  stomach  exactly  analogous  to  the 
inhibition  of  the  vasoconstrictor  nerves,  which  induces 
blushing.  In  this  way,  in  nervous  conditions,  there  is 
produced  a  potential  or  actual  relaxation  of  the  stomach 
walls,  so  that  the  organ  is  easily  inflated  by  air  swallowed 
with  the  food  or  between  meals.     At  the  same  time  that 


FLATULENCE  303 

the  explosive  eructations  are  going  on,  some  of  the  air  may 
be  forced  through  the  pylorus,  giving  rise  to  intestinal 
flatulence. 

A  most  annoying  trouble  due  to  a  neurosis  is  the  passage 
of  air  through  the  intestines,  and  the  accompanying  rum- 
bling denominated  borborygmus.  It  is  increased  under 
emotional  stress  like  aerophagia,  and  the  anxiety  over  it 
increases  it  still  more.  Old  men  seldom  complain  of  it  to 
their  physicians,  but  middle-aged  or  elderly  women  find 
it  a  keen  source  of  embarrassment.  Seldom  it  is  found  in 
young  women,  except  those  of  extremely  neurotic  tempera- 
ment. The  older  female  sufferers  are  often  stout,  with 
relaxed  and  incompetent  abdominal  walls,  so  that  the  empty 
intestines  do  not  fall  together  as  they  should,  but  rather 
tend  to  lie  apart,  allowing  spaces  between  which  the  atonic 
intestinal  walls  "balloon",  thus  favoring  an  accumulation  of 
gas.  Often  after  these  patients  have  been  exercising  to  the 
point  of  fatigue,  and  sit  down  inside  a  warm  room,  the 
expansion  of  air  in  the  intestines  quickly  leads  to  rumbling 
there,  with  the  production  of  flatus.  This  experience  is 
quite  common  with  elderly  people  in  cold  weather,  and 
the  odor  of  the  flatus,  when  passed,  is  but  slightly  offen- 
sive. 

In  young  women,  when  troubled  with  flatulence  or  bor- 
borygmus, it  often  makes  them  so  nervous,  and  leads  to 
such  dread,  that  it  hinders  their  participation  in  social 
usages,  makes  them  fear  to  associate  with  any  but  their 
immediate  family,  and  occasions  the  most  poignant  mental 
suffering.  Some  young  women  suffer  from  rumbling  in  the 
intestines  whenever  more  than  four  hours  have  passed  since 
their  last  meal.  This  phenomenon  is  more  likely  to 
manifest  itself  when  they  are  nervous  and  excited,  but  is 
specially  liable  to  mainfest  itself  when  they  are  with  people 
whom  they  desire  to  impress  favorably.  Dread  and  fear 
play  a  large  part  in  this  nervous  rumbling,  and  it  is  probably 
due  to  an  exaggeration  of  peristalsis,  and  the  crowding  into 
large  intestinal  spaces  small  collections  of  air  that  under 


304  PSYCHOTHERAPY   IN    GASTROINTESTINAL ,  DISEASES 

normal  peristalsis  would  escape  from  one  portion  of  the 
gut  to  another  without  audible  sound. 

Moral  suasion  and  encouragement,  with  the  injunction  to 
always  eat  a  light  lunch  when  the  slightest  sensation  of 
emptiness  is  felt,  will  greatly  aid  this  embarrassing  condi- 
tion. It  is  often  necessary  to  give  in  addition  an  alkaline 
carminative,  and  to  enforce  certain  hygienic  regulations,  as 
there  is  often  a  material  aspect  that  psychotherapy  alone 
will  not  control. 

Many  individuals,  especially  women,  who  adopt  a 
sedentary  occupation  and  lose  in  weight  suffer  from  both 
borborygmus  and  excessive  sensitiveness  of  the  intestines. 
The  same  management  as  that  just  suggested  will  generally 
prove  satisfactory. 

Bad  Breath. — Certain  odors  from  the  body  are  una- 
voidable— they  are  inherent,  a  characteristic  of  physical 
organization,  and  a  consequence  of  metabolic  activities. 
Some  of  the  odors  peculiar  to  an  individual  may  be  pleasant 
or  otherwise.  In  the  Song  of  Solomon,  that  wise  old 
monarch  grew  enthusiastic  over  the  pleasant  aroma  em- 
anating from  the  body  of  his  "beloved." 

In  the  ordinary  intercourse  between  people,  the  exhaled 
breath  generally  constitutes  the  most  noticeable  odor, 
though  in  some  instances  the  breath  is  but  one  part  of  a 
comprehensive  effluvia  originating  from  the  whole  body, 
as  illustrated  in  pellagra. 

To  the  laity  and  the  superficial  student,  a  bad  breath 
means  one  of  two  conditions — an  unwholesome  oral  cavity, 
or  a  "spoiled  stomach."  There  are  several  other  under- 
lying causes  for  bad  breath,  such  as  necrosis  of  the  nasal 
bones,  purulent  rhinitis,  ozena,  septic  tonsillitis,  Vincent's 
angina,  etc.  Apart  from  conditions  in  the  mouth,  and 
the  causes  just  mentioned,  let  me  mention  absorption  from 
the  intestines.  When  protein  putrefaction  takes  place 
in  the  small  intestine,  or  when  an  excess  protein  putrefac- 
tion occurs  in  the  large  intestine,  the  end  products,  which 


BAD   BREATH  305 

the  ordinary  emunctories  cannot  care  for,  are  eliminated 
through  the  expired  breath. 

When,  therefore,  nervous  patients  are  unduly  worried 
about  a  bad  breath,  they  should  be  informed  that  the 
stomach  proper  is  seldom  to  blame,  that  when  their  teeth 
are  put  in  order,  when  their  intestinal  tracts  are  kept 
normal,  when  an  abundance  of  water  is  drunk,  and  when 
by  a  cheerful,  hygienic  and  active  life  their  bodies  and  minds 
are  placed  in  what  Huxley  calls  a  state  of  "moving  equi- 
librium," the  bad  breath  will  depart  with  many  of  the  other 
digestive  discomforts. 

General  Principles  of  Psychotherapy  as  Applied  to 
Various  Forms  of  Indigestion. — Let  me  affirm  as  a  proven 
fact  that  there  are  but  few  gastrointestinal  diseases,  no 
matter  how  material  or  far  advanced,  but  what  psycho- 
therapy possesses  for  them  a  beneficent  function.  Even 
where  a  fatal  termination  is  assured,  and  nothing  can  be 
done  for  the  disease,  something  may  be  done  for  the  patient, 
either  by  diverting  the  mind,  or  keeping  alive  the  spark  of 
hope,  without  which  all  would  be  blank  despair.  This  is 
the  most  that  can  be  expected  in  such  melancholy  condi- 
tions, but  because  a  cure  is  not  in  view,  the  physician  should 
not  cease  his  efforts  to  infuse  courage  and  cheer  into  the 
mind  of  the  invalid.  There  are  several  reasons  for  this. 
In  the  first  place,  there  is  a  possibility  that  the  fatal 
prognosis  is  a  mistaken  one.  Many  instances  are  on 
record  in  which,  after  an  unfavorable  prognosis  Vv^as  given, 
the  patient  recovered,  outliving  the  physician  vv^ho  made 
the  prognosis;  again,  there  may  be  a  mistake  in  the  diag- 
nosis, or  the  patient  may  possess  a  recuperative  power  not 
realized  by  the  medical  attendant.  There  are  many  ob- 
jections to  a  gloomy  prognosis,  even  under  the  most  un- 
favorable outlook,  and,  if  the  physician  will  use  to  the 
uttermost  any  little  grains  of  encouragement,  while  he 
says  as  little  as  possible  concerning  the  less  favorable 
aspects  of  the  case,  his  influence  on  the  course  of  the  disease 


3o6         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

will  necessarily  be  uplifting;  and  he  need  not  utter  a  single 
deceptive  word. 

The  Personal  Equation. — Some  physicians  possess  a 
personality  which  in  itself  inspires  confidence,  though 
any  one  has  within  his  power  the  faculty  of  cheerfulness 
and  optimism.  Undue  levity  in  a  sick  room  is  of  course 
to  be  deprecated,  and  to  laugh  at  a  patient's  recital  of 
woes,  even  though  they  be  ridiculous,  is  nearly  always 
harmful.  Ridicule  has  no  legitimate  place  in  rational 
psychotherapy.  A  warm-hearted  grasp  of  the  hand  on 
greeting  a  patient;  a  cheerful  and  smiling  but  earnest 
countenance,  betokening  a  real  desire  to  be  of  assistance; 
a  sympathetic  interest  in  the  recital  of  infirmities — all 
these  attributes  on  the  part  of  the  physician,  will  gain 
the  patient's  confidence,  and  will  ensure  a  receptive  attitude 
for  every  therapeutic  effort  that  may  be  later  brought  to 
bear.  Every  one  has  heard  some  person  remark  that  a 
certain  doctor's  medicine  helped  him  more  than  some  other 
doctor's,  because  he  had  more  confidence  in  the  former. 
This  is  a  simple  exemplification  of  both  the  influence  of 
the  personal  equation  and  psychotherapy  itself. 

One  of  the  first  essentials  in  entering  upon  the  treatment 
of  a  gastrointestinal  disease,  especially  if  it  be  chronic,  is 
a  thorough  and  systematic  examination — more  thorough, 
if  possible,  than  any  the  patient  has  previously  undergone. 
This  has  a  double  advantage — it  bestows  upon  the  physician 
an  intelligent  knowledge  of  past  and  present  conditions,  and 
it  convinces  the  patient  that  a  deep  interest  is  being  taken. 

Another  point  worth  mentioning  is  the  desirability  of 
inaugurating  some  form  of  treatment,  no  matter  how 
insignificant,  as  early  as  possible  after  taking  charge  of 
the  case.  While  a  leisurely  amount  of  deliberation  is 
necessary  and  praiseworthy,  the  viewpoint  of  the  patient 
is  from  a  different  angle,  and,  if  the  physician  dallies  too 
long,  he  will  lose  some  of  his  influence.  A  placebo  can  do 
no  harm,  and  it  will  keep  the  patient  in  a  more  satisfied 
frame  of  mind,  until  the  diagnosis  is  fully  made.     When  a 


THE    PERSONAL    EQUATION  307 

patient  goes  to  a  physician,  he  expects  treatment,  and  if 
something  apparently  tangible  is  not  done  very  soon, 
even  the  most  intelligent  patient  will  feel  a  shade  of 
disappointment  or  dissatisfaction;  and,  if  less  intelligent, 
may  indulge  in  open  rebellion. 

There  are  conditions  of  this  sort  that  confront  every 
physician,  and  he  can,  by  the  exercise  of  tact  and  per- 
sonality, overcome  them  with  perfect  dignity  and  no 
stultification  of  his  professional  standing.  First  impres- 
sions are  often  lasting,  and  that  the  first  impressions  in 
the  mind  of  a  patient  toward  the  physician  may  be  those  of 
confidence,  is  important  in  the  extreme. 

Psychotherapy  in  regard  to  Diet. — A  few  patients  com- 
plaining of  digestive  disturbances,  especially  chronic  forms, 
are  suffering  from  excessive  eating;  rather  more  from  in- 
judicious use  of  stimulants;  while  the  majority,  in  my 
experience,  suffer  fron  underfeeding.  Practically  all  of 
these  dyspeptics  are  on  a  diet,  either  self-imposed,  or 
instituted  by  a  physician  months  or  years  previously. 
This  diet  is  often  totally  inadequate  to  furnish  the  neces- 
sary calories  required  by  ordinary  demands  of  the  body, 
consequently  the  body  is  ill-nourished,  the  nervous  poise 
is  rendered  unstable  by  physical  weakness,  and  the  patient 
is  still  less  able  to  fight  the  inroads  of  disease.  In  many 
instances  the  hunger  pains,  the  weakness,  the  emotional 
outbursts,  and  the  countless  vague  discomforts  which 
accompany  slow  starvation,  are  mistakenly  attributed  to 
indigestion,  QXid  the  diet  is  still  further  restricted.  These 
ill-nourished  sufferers  have  generally  developed  a  sitophobia, 
or  fear  of  food,  and  it  will  require  every  effort  of  the  phy- 
sician to  overcome  this  fear.  If  after  careful  examination, 
there  is  found  present  a  working  quantity  of  digestive 
juices,  and  the  motility  is  not  radically  impaired  by  organic 
lesions,  the  dietary  should  be  generously  increased,  while 
strenuous  endeavors  should  be  instituted  to  change  the 
mental  attitude  of  fear  into  one  of  courage  and  confidence. 
Here  is  the  opportunity  for  psychotherapy. 


3o8         PSYCHOTHERAPY   IN   GASTROINTESTINAL   DISEASES 

I  often  tell  these  timorous  patients  that  there  is  posi- 
tively enough  gastric  juice  present  for  their  needs;  that 
if  they  will  eat  the  food  as  I  urge,  I  will  help  them  with 
its  digestion;  and  that  they  need  fear  absolutely  no  evil 
consequences. 

In  som.e  cases  the  digestive  organs,  which  have  had  noth- 
ing to  do  for  so  long,  will  for  a  while  rebel,  and  the  patient 
will  suffer  from  colicky  pains  and  some  soreness.  This  is 
explained  by  the  comparison  of  heavy  muscular  labor 
performed  by  one  who  has  long  led  a  sedentary  life  and  the 
consequent  soreness,  which  will  pass  away  if  the  exercise 
is  continued.  Thus,  after  the  stomach  and  intestines  have 
adjusted  themselves  to  the  new  and  more  liberal  regimen, 
with  increased  bodily  strength,  there  will  be  noted  increased 
nervous  stability,  a  more  cheerful  view  of  life,  and  a  general 
feeling  of  comfort  and  well-being. 

As  an  illustration  of  nearly  every  point  here  discussed,  I 
can  cite  the  case  of  a  lady  of  fifty-eight  years,  who  came 
under  my  care  nearly  a  year  ago.  She  was  suffering  from 
an  organic,  but  non-malignant  stricture  of  the  esophagus, 
which  had  so  reduced  the  lumen  of  that  canal,  that  she 
could  only  take  liquid  nourishment  and  in  teaspoonful 
quantities  at  a  time. 

She  was  thin,  nervous,  emotional,  constipated,  suffering 
from  insomnia,  and  complaining  of  constant  "indigestion." 
She  was  habitually  taking  medicine  for  the  three  complaints 
■ — constipation,  indigestion,  and  insomnia.  Her  esophageal 
obstruction  had  been  incorrectly  diagnosed  as  a  "nervotis 
affection,"  though  never  explored  with  a  sound. 

The  stricture  was  dilated  with  comparative  ease,  until  a 
20  English  sound  could  be  passed  with  facility.  She  was 
then  told  to  increase  and  diversify  her  daily  bill-of-fare, 
and  a  simple  alkaline  carminative  was  given  her  mainly  as 
a  placebo.  She  was  quite  fearful  that  her  stomach  would 
not  "bear"  solid  food,  but  having  won  her  confidence, 
and  after  earnest  assurances  that  she  was  able  to  digest 
what  I  recommended,  she  began  to  eat. 


CHANGE    OF    ENVIRONMENT  309 

After  about  a  dozen  good  meals  the  pains  of  the  supposed 
indigestion  began  to  disappear,  and  in  two  weeks  they 
were  gone.  She  found,  to  her  delight,  that  she  could  sleep 
without  her  accustomed  "Sleeping  draught,"  her  fits  of 
crying  ceased,  her  disposition  became  bright  and  happy,  and 
with  increased  weight  and  vigor  came  satisfaction  with  her 
daily  life.  It  is  still  necessary  to  keep  the  stricture  dilated 
at  intervals,  but  she  has  gained  about  30  pounds,  and  at 
present  seems  in  perfect  bodily  and  mental  health. 

Another  important  adjunct  to  the  application  of  suc- 
cessful psychotherapy  in  digestive  diseases,  is  to  look  after 
the  small  and  intercurrent  ills  as  they  arise.  If  the  phy- 
sician will  take  sympathetic  cognizance  of  the  minor 
complaints,  and  will  make  minor  concessions  in  unimpor- 
tant matters,  he  will  find  that  he  can  better  exert  his 
authority  in  important  matters.  Chronic  dyspeptics  have 
more  than  the  usual  share  of  human  frailties,  and  if  the 
physician  attempts  to  entirely  revolutionize  their  habits 
and.  customs,  he  may  so  upset  and  discourage  them, 
that  they  will  not  make  the  proper  effort  to  get  well  or  to 
co-operate  with  him. 

If  they  can  have  their  way  in  non-essentials,  they  will 
much  more  readily  yield  to  advice  in  essentials. 

Change. — This  one  word  sometimes  solves  the  whole 
therapeutic  problem.  It  is  noticeable  that  one's  digestion 
is  always  good  on  a  holiday,  and  many  people  find  that  they 
can  with  impunity  eat  articles  of  food  while  on  a  vacation 
or  pleasure  trip,  which  would  profoundly  disturb  them  at 
other  times.  On  such  occasions  the  mind  is  generally 
care-free,  the  thoughts  are  on  external  objects,  while  the 
attention  is  diverted  from  the  stomach  and  all  that  per- 
tains to  it. 

It  is  not  always  practicable  to  send  a  patient  on  a 
protracted  vacation,  nor  can  we  always  arrange  a  radical 
change  in  his  business  habits.  When  it  is  possible,  how- 
ever, the  greater  the  change,  within  the  limits  of  comfort 
and  propriety,  the  greater  the  probable  benefit.     To  take 


3IO         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

the  wearied  book-keeper  from  his  desk,  and  put  him  "on 
the  road"  for  a  while;  to  place  the  road- worn  traveling 
man  in  the  quiet  haven  of  ah  office;  to  send  the  blase 
city  man  out  among  the  green  trees  and  meadows  of  the 
country;  or  to  take  the  housewife,  who  has  grown  sick  and 
weary  under  the  monotony  of  life  in  some  isolated  com- 
munity, and  let  her  enjoy  the  bustle  and  sights  of  a  great 
city  for  a  season — all  these,  and  others  that  ingenuity  or 
practicability  may  suggest,  will  in  •  many  instances  vary 
the  diseased  current  of  digestive  thought  and  banish  the 
introspection,  the  self-analysis,  the  self-pity. 

Cheerful  Companionship  and  Environment. — When  the 
man  Of  wisdom  said,  "A  merry  heart  doeth  good  like  medi- 
cine," he  uttered  a  truism  that  applies  to  twentieth-century 
civilization,  as  well  as  ancient  times.  The  lack  of  socia- 
bihty  and  good  cheer  at  the  table  predisposes  to  indiges- 
tion, while  the  business  man  who  eats  his  breakfast  with 
his  face  buried  in  a  morning  paper,  with  not  a  pleasant 
smile  for  any  one,  who  eats  his  lunch  in  sour  solitude  and 
with  gastronomic  contemplation,  is  much  more  liable  to 
the  pangs  of  indigestion  than  the  cheerful  one,  who  inter- 
sperses the  progress  of  his  meals  with  pleasant  anecdotes 
or  bright  and  entertaining  conversation.  If  I  were  asked 
to  advise  between  a  hurried  ^meal  with  good  cheer,  or  a 
deliberate  meal  with  anger  or  disgust  as  its  accompani- 
ment, I  would  assuredly  choose  the  former  for  safety. 

It  is  worth  the  thought  and  time  of  the  physician  to 
regulate  for  good,  if  possible,  the  environment  of  every 
chronic  dyspeptic,  otherwise  many  a  well-chosen  pre- 
scription will  come  to  naught  in  the  presence  of  petty 
worries  and  repinings  that  seem  to  act  with  malign  force 
on  the  digestive  organs. 

A  confrere  recently  reported  to  me  the  case  of  a  young 
lady  who  had  long  been  troubled  with  nervous  indigestion, 
and  who  was  quickly  relieved  after  changing  her  boarding 
place  which  was  rather  somber,  and  which  numbered 
among  its  patrons  some  crusty  and  disagreeable  individuals 


THE   REST   CURE  3II 

who  made  her  excessively  nervous.  This  physician  not 
only  insisted  that  she  make  the  change,  but  saw  to  it  that 
she  was  established  in  pleasant  and  congenial  surroundings, 
and  the  good  results  justified  his  expectations. 

The  Rest  Cure. — This  unique  method  for  treating 
nervous  and  emaciated  invalids  we  owe  to  Dr.  Weir  Mitchell, 
and,  where  practicable  to  carry  out,  it  will  sometimes 
accomplish  remarkable  results.  It  consists  of  a  stay 
of  six  weeks  or  two  months  in  a  well-organized  sanitarium, 
complete  rest  in  bed  for  four  or  six  weeks,  and  complete 
isolation  in  the  meanwhile.  During  the  greater  part  of 
this  time  the  patient,  if  a  woman,  is  not  permitted  to  even 
brush  her  hair  or  rise  for  any  of  her  necessary  functions. 
Everything  is  attended  to  by  a  nurse  trained  for  such 
care.  She  is  told  to  cultivate  an  absolute  mental  vacuity, 
and,  as  far  as  possible,  she  should  lead  a  vegetative 
existence. 

During  the  first  five  or  six  days  nothing  but  sweet  milk 
is  given,  beginning  with  24  ounces,  divided  into  eight 
portions,  given  two  hours  apart  from  7  a.  m.  to  9  p.  m., 
and  increased  to  60  ounces,  divided  into  equal  portions, 
and  given  at  the  same  hours.  The  milk  should  be  either 
fed  to  the  patient  from  a  spoon  or  slowly  sipped.  Some- 
times I  give  it  hot.  On  the  seventh  day  the  regimen 
changes  abruptly,  and  without  transition  may  be  pre- 
scribed for  breakfast  12  ounces  of  milk,  with  bread  and 
butter,  honey  or  preserves.  At  ten  in  the  morning  a  full 
glass  of  milk.  For  dinner  (or  lunch)  a  full  meal  of  tender 
vegetables,  roast  meat,  or  fish,  with  bread  and  butter, 
some  light  dessert,  and  a  glass  of  milk.  At  four  in  the 
afternoon  give  a  full  glass  of  milk.  Supper  (or  dinner) 
may  consist  of  one  or  two  eggs,  bread  and  butter  or  jelly, 
and  a  glass  of  milk.  At  nine  o'clock  a  final  glass  of  milk 
should  be  taken,  preferably  hot. 

There  may  be  some  fulness,  and  perhaps  distention,  the 
first  two  or  three  days'  of  this  liberal  regimen,  but  if  the 
patient  is  put  in  the  proper  mental  attitude,  the  discomfort 


312         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

is  minimized.  The  physician  must  dispel  the  fears  of 
indigestion,  and  insist  upon  the  necessity  of  overfeeding 
in  order  to  quickly  get  her  out  of  the  sad  condition  of 
malnutrition.  If  the  patient  says  she  cannot  eat  because 
she  is  constipated,  explain  that  an  abundant  diet  will 
overcome  the  constipation;  that  the  residue  of  the  food 
left  in  the  intestines  will  stimulate  action,  and  that  large 
eaters  are  never  constipated.  If  the  bowels  do  not  move 
sufficiently  at  first,  give  one  or  more  small  enemas,  until 
fecal  results  are  obtained.  This  may  be  kept  up  for  a  few 
days  if  necessary,  but,  if  the  proper  efforts  are  made, 
natural  movements  will  soon  be  attained.  For  the  dis- 
tention of  the  abdomen,  which  sometimes  is  annoying 
for  a  few  days,  there  may  be  applied  hot  moist  compresses 
or  turpentine  stupes,  and,  when  absolutely  demanded, 
not  by  the  patient  but  by  the  symptoms,  there  may  be 
administered  a  few  doses  of  some  simple  carminative.  The 
last-named  measure,  however,  should  be  avoided,  if  pos- 
sible, for  it  is  expedient  to  get  the  patient's  mind  and  body 
entirely  away  from  the  thought  and  habit  of  taking 
medicine  for  the  abdominal  hyperesthesia. 

If  the  physician  will  enforce  this  regimen,  and  fortify 
it  with  positive  and  courageous  psychotherapy,  the 
overfeeding  will  be  well  endured  in  the  vast  majority  of 
cases. 

The  effect  of  this  treatment,  from  the  point  of  view  of 
nutrition,  naturally  varies  according  to  cases.  The  first 
week,  when  the  food  is  insufficient,  does  not  generally 
show  any  increase  of  body  weight.  Patients  who  ate 
heartily  before,  grow  thin.  They  may  lose  in  the  first 
seven  days  from  i  to  7  pounds.  Some  remain  stationary, 
their  previous  insufficient  diet  being  equivalent  to  the  milk 
diet.  Only  those  who  are  much  emaciated  succeed  in  gain- 
ing as  much  as  two  or  three  pounds  during  the  first  week. 
The  result  of  the  first  week  is  not  important,  but  it  is  wise 
to  have  the  patient  forewarned,  so  that  discouragement  will 
not  add  to  the  other  burdens. 


THE   REST   CURE  313 

At  the  end  of  the  second  week  there  should  be  a  marked 
increase  in  weight  and  the  greater  it  becomes  the  more 
it  affects  the  mental  and  physical  well-being.  This  in- 
crease may  vary  from  5  to  7  or  8  pounds  a  week,  and  Dubois 
reports  one  patient  in  whom  there  was  an  increase  in  weight 
of  II  1/2  pounds  in  one  week. 

As  the  time  goes  on,  the  physician  should  congratulate 
the  patient  on  every  gain,  should  keep  up  flagging  courage, 
and,  if  there  is  any  failure  to  attain  desired  results  one 
week,  should  redouble  every  effort  toward  attaining  success 
the  next  week. 

This  method  of  treatment  will  require  time,  patience, 
tact,  and  co-operation  on  the  part  of  a  good  nurse,  but, 
if  carried  out,  the  results  are  most  brilliant  and  lasting. 

Dubois  says  "The  physician  should  not  only  be  a  wise 
man  who  practises  on  his  patient  a  sort  of  vivisection,  but 
he  ought  to  be,  before  all,  a  man  of  heart  who  knows  how 
to  put  himself  in  the  place  of  those  who  suffer.  In  the 
domain  of  nervousness  this  fallacious  precision  of  diagnosis 
is  dangerous.  I  have  said  that  the  idea  and  the  mental 
representation  play  an  important  role  in  the  genesis  of 
all  the  psychoneuroses,  and  the  physician  runs  a  great 
risk  of  confirming  the  hypochondriacal  condition  of  the 
patient.  He  should  avoid  this  danger  by  developing 
these  qualities  of  the  observer  in  learning  to  judge  his 
cases  as  a  whole,  without  the  need  of  exhausting  all  methods 
of  research." 

I  might  add  that  pithy  proverb,  "Observations  are  not 
to  be  numbered,  but  weighed." 

The  psychoanalytic  method,  as  advanced  by  Freud, 
has  not  as  yet  been  applied  very  extensively  to  the  manage- 
ment of  gastrointestinal  disorders.  It  is  to  be  hoped,  how- 
ever, as  psychoanalysis  becomes  more  understood  and 
appreciated,  that  its  uses  may  be  broadened,  and  that  it 
may  be  found  a  useful  ally  to  other  methods  of  psycho- 
therapy. 

Finally,  I  might  say,  that  in  the  exercise  of  this  refine- 


314         PSYCHOTHERAPY   IN    GASTROINTESTINAL   DISEASES 

ment  of  therapy,  cognizance  should  generally  be  taken 
of  tangible  bodily  ailments,  and  a  certain  amount  of 
appropriate  xnedication  has  its  important  place  even  in 
the  exercise  of  psychotherapy.  He,  though,  who  attempts 
to  reach  the  shifting  and  evanescent  psychoneurosis  of 
digestion  by  a  strict  system  of  dietetics,  stomachics, 
digestants,  tonics,  or  any  other  adventitious  aids,  will  be 
foredoomed  to  failure.  Along  the  line  of  uplifting  sugges- 
tion the  '  'isms ' '  and  cults  have  won  some  of  their  spectacular 
victories,  and  the  medical  profession  has  been  far  too 
slow  to  gather  from  these  erratic  creeds  the  few  real 
jewels  they  contain. 

When,  therefore,  by  means  of  both  material  and  psychic 
therapy,  intelligently  and  energetically  applied,  the  minds 
of  these  sorrowful  invalids  are  taken  from  their  stomachs ; 
when  their  daily  thoughts  are  lifted  out  from  introspective 
grooves;  when  their  ill-nourished  bodies  are  furnished 
sufficient  food,  and  their  desiccated  tissues  laved  with  an 
abundance  of  water — then  can  the  vicious  circle  be  broken, 
and  the  psychic  aids  to  digestion  resume  their  normal  place 
in  the  bodily  economy. 


CHAPTER  XIII 
GENERAL  CONSIDERATIONS  OF  DIET 

The  health  and  welfare  of  individuals  and  of  peoples 
depend  on  right  methods  of  living,  and  of  all  methods  of 
living  the  most  momentous  are  those  relating  to  the  upkeep 
of  the  body  by  alimentation.  It  is  food  that  supplies 
the  material  for  that  perpetual  series  of  transformations 
in  which  life  consists,  and  it  must  be  adequate  in  quantity 
and  suitable  in  quality  if  these  transformations,  of  so 
many  different  kinds,  in  so  many  different  organs,  are 
to  proceed  with  that  nicely  balanced  adjustment  that  is 
known  as  health.  Fuel  for  heat  and  energy,  material 
for  repiair  in  proportion  to  work  done  and  waste  incurred, 
must  be  requisitioned,  if  a  man  is  to  live  and  prosper,  and 
any  excess  or  deficiency  in  these  is  followed  by  impair- 
ment of  strength  and  vigor,  by  tissue-degeneration  and  by 
diminished  resistance  to  the  inroads  of  disease  (Crighton- 
Browne) . 

The  principles  of  nutrition,  are  therefore,  important 
not  only  in  preventive  medicine,  but  in  therapeutics  as 
well. 

The  study  of  foods  is  a  most  complex  one,  and  many 
experiments  are  being  constantly  made  throughout  the 
world  to  the  end  that  the  principles  of  diet  may  be  lifted 
out  of  the  realms  of  both  empiricism  and  obscurity,  and 
placed  where  they  may  be  easily  understood  and  in- 
telligently followed. 

Food  Classification. — Foods  may  be  classified  according 
to:  (i)  Their  physical  properties.  (2)  Their  source.  (3) 
Their  composition.  (4)  The  functions  they  perform  in  the 
animal  body. 

315 


3l6  GENERAL   CONSIDERATIONS    OF   DIET 

(i)  They  may  be  divided  into  solid,  liquid,  semi-solid, 
fibrous,  gelatinous,  starchy,  oleaginous,  crystalline,  and 
albuminous  foods. 

(2)  Foods  are  derived  from  the  animal  and  vegetable 
kingdom.  Of  the  former  are  meats,  fowl,  fish,  shellfish, 
crustaceans,  insects  and  their  products  (honey,  for  instance) , 
eggs,  milk,  milk  products,  animal  fats,  gelatin.  Of  the 
latter,  are  cereals,  vegetables,  fruits,  sugars,  gums,  vegetable 
oils  and  fats. 

As  to  the  chemic  classification,  the  simplest  is  that  by 
Von  Liebig,  who  divided  them  into  nitrogenous  and  non- 
nitrogenous. 

The  present  generally  accepted  chemic  classification 
consists  of  proteins,  carbohydrates,  fats,  inorganic  salts,  and 
water. 

The  proteins  include  all  nitrogenous  food  substances, 
examples  of  which  are  the  lean  fiber  of  meat  and  the  gluten 
of  grain. 

The  carbohydrates  contain  no  nitrogen,  being  composed 
of  carbon,  hydrogen,  and  oxygen,  and  include  the  starches, 
sugars,  and  vegetable  fiber  or  cellulose. 

The  fats  serve  the  same  purpose  as  carbohydrates,  but 
are  more  concentrated,  though  less  easily  utilized.     Fat  is 
found  in  animal  foods,  as  meat,  fish  and  butter,  and  in 
the  vegetable  kingdom,  as  oils,  in  the  various  cereals,  and . 
in  the  kernels  of  nuts. 

The  inorganic  salts,  as  calcium  phosphate,  and  the 
various  compounds  of  'potassium,  sodium,  magnesium,  and 
iron,  furnish  neither  heat  nor  energy,  but  are  necessary  to 
life  and  health. 

Water  enters  into  the  composition  of  every  tissue  of  the 
body,  and  forms  more  than  60  per  cent,  of  the  entire  body 
weight  of  an  adult  man.  It  is  not  burned  up  in  the  metabolic 
processes  of  the  body,  but  is  essential  to  life. 

Proteins  are  of  the  greatest  importance  to  the  body,  for 
without  them,  or  in  insufficient  quantity,  the  body  wastes, 
and  malnutrition  takes  place.     They  help  to  build  up  new 


QUANTITY  or  FOOD  IN  HEALTH  317 

tissue,  and  repair  the  waste  of  the  old;  they  are  also 
consumed  in  the  body,  being  valuable  as  a  source  of  energy 
and  heat.  Further,  they  may  be  converted  into  fat,  and 
stored  in  the  body  for  future  use  in  emergencies  of  nutrition. 
This  last  function  is  of  somewhat  minor  importance. 

Carbohydrates  are  burned  up  in  the  body,  and  their 
energy  is  changed  into  heat  or  used  up  in  muscular  work; 
they  may  also  be  converted  into  fat,  and  stored  up  in  the 
body.  Starch  forms  about  i  per  cent,  of  the  body  weight, 
and  the  carbohydrates,  on  account  of  their  easy  digestion 
and  availability,  are  the  most  prolific  source  of  heat  and 
energy. 

Quantity  of  Food  Required  in  Health. — This  varies  as 
to  age,  occupation,  and  condition  of  body.  A  man 
naturally  requires  more  than  a  child,  a  man  at  work  more 
than  one  at  rest,  etc. 

Voit  insists  that  the  ideal  diet  consists  of  the  smallest 
amount  of  protein  food,  together  with  non-nitrogenous 
food,  that  will  keep  the  body  in  a  state  of  vigor.  He  holds 
that  a  healthy  adult  of  average  weight  should  ingest  loo 
grams  of  albumen,  50  grams  of  fat,  and  450  grams  of 
carbohydrate  in  twenty-four  hours.  Others  place  the 
protein  requirement  somewhat  higher,  and  I  am  inclined  to 
think  that  120  grams  of  this  element  constitute  a  more 
suitable  number. 

A  small  proportion  of  the  food  serves  for  reconstructing 
tissue  waste,  while  the  major  part  is  used  for  generating 
the  heat  required  for  the  maintenance  of  life,  and  to  furnish 
energy  for  the  functions  of  life.  It  is,  therefore,  customary 
to  speak  of  the  number  of  heat  units  (calories)  necessary 
during  the  twenty-four  hours  instead  of  the  quantity  of 
food. 

A  calorie  (or  heat  unit)  may  be  defined  as  the  amount  of 
heat  required  to  raise  the  temperature  of  i  gram  of  water 
1°  C  This  is  a  small  calorie.  A  large  calorie  is  the 
amount  required  to  raise  the  temperature  of  i  kilogram  of 
water  1°  C.     Therefore  a  large  calorie  equals  1000  small 


3l8  GENERAL   CONSIDERATIONS    OF   DIET 

calories.     This  distinction  should  not  be  forgotten,  other- 
wise great  confusion  may  arise. 

From  Rubner's  investigations  we  learn  that 

One  gram  of  protein  =   4.1  calories. 

One  gram  of  fat  =   9.3  calories. 

One  gram  of  carbohydrates  =   4.1  calories. 

In  order  to  calculate  the  caloric  value  of  any  food,  the 
number  of  grams  of  albumen  contained  in  it  are  multiplied 
by  4.1 ;  the  grams  of  carbohydrates  by  4. i ;  and  the  grams  of 
fat  by  9.3.  These  being  added  together,  give  the  total 
caloric  value  of  the  food. 

Riegel  holds  that  a  human  being  at  rest  demands  about 
3  5  calories  per  kilogram  of  body  weight,  and  one  performing 
light  work  about  40  calories  per  kilogram.  From  [his 
estimate  the  caloric  value  of  the  food  of  an  individual 
weighing  50  kilos  is  from  1750  to  2000  calories. 

Hutchinson  gives  the  following : 


The  quantity  of  protein  consumed  daily  is  100  grm.  X  4.  i   =     410 
The  quantity  of  carbohydrates  daily  is  500  grm.  X  4.  i  =  2050 

The  quantity  of  fats,  daily  is  50  grm.  X  9 . 3  =     465 


2925 


The  average  number  of  calories  required  daily  by  an 
individual,  according  to  this  calculation,  is  approximately 
3000,  and  is  more  suited  for  the  needs  of  an  active  man  than 
Voit's. 

The  question  of  the  appropriate  protein  daily  intake  is 
one  that  is  met  by  divergent  opinions.  Rubner  claims  that 
the  different  articles  of  food  replace  each  other  according  to 
their  caloric  value,  and  it  is  immaterial  in  what  form  the 
calories  are  taken  into  the  body.  This  is  true  only  within 
certain  limits. 

Russel  H.  Chittenden  has  demonstrated  to  his  satisfac- 
tion, by  experiments  carried  on  under  favorable  circum- 


FOOD   REQUIREMENTS  319 

stances,  and  assisted  by  colleagues  of  high  scientific  at- 
tainments, that  the  recommended  dietary  standards  are 
excessive  in  quantity,  especially  in  regard  to  proteins. 

Briefly  stated,  his  conclusion  is  that  the  daily  amount  of 
protein  or  albuminous  food  required  for  the  maintenance 
of  health  and  vigor  is  not  more  than  one-half  that  hitherto 
regarded  as  necessary.  Observations  upon  groups  of 
professional  men,  army  volunteers,  university  athletes 
and  animals  have  satisfied  Chittenden  that  for  a  man 
weighing  70  kilograms,  or  154  pounds,  there  would  be 
required  daily  59.5  grams — say  60  grams  of  protein  food 
to  meet  all  the  needs  of  the  body.  To  quote  him — 
"These  are  perfectly  trustworthy  figures  with  a  reasonable 
margin  of  safety,  and  carrying  perfect  assurances  of  really 
being  more  than  sufficient  to  meet  the  true  wants  of  the 
body,  adequate  to  supply  all  physiological  demands  for 
reserve  protein,  and  able  to  cope  with  the  erratic  require- 
ments of  personal  idiosyncrasies." 

It  is  impossible  and  out  of  place  to  here  systematically 
review  Chittenden's  work,  or  even  to  follow  up  his  ex- 
periments and  show  where,  notwithstanding  the  careful 
precautions  taken,  possibilities  of  fallacy  exist,  or  to  point 
out  in  what  directions  further  investigation  is  advisable. 
It  must  be  admitted  that  he  has  made  out  a  strong  case, 
and  has  shaken  to  its  base  the  fabric  of  established  opinions 
on  food  questions  on  the  physiologic  side,  but  he  has  not 
yet  overthrown  it,  and  I  submit  tht  we  should  pause  before 
accepting  his  views  in  toto,  or  proceeding  to  revise  from 
the  foundation,  our  whole  system  of  practical  dietetics, 
and  to  cut  down  by  half  the  ordinary  meat  ration. 

If  Chittenden  is  right,  the  whole  dietetic  system  has  been 
wrong  from  the  foundation  of  the  earth,  and  while  the 
triumphs  of  modern  science  in  revolutionizing  our  ideas 
as  to  diphtheria,  typhoid  fever,  malaria,  etc.,  may  be  cited, 
there  is  a  scant  analogy  between  the  cases.  In  the  one, 
science  is  dealing  with  an  accidental  and  external  cause  of 
disease;  in  the  other  with  a  universal  and  constitutional 


320  GENERAL    CONSIDERATIONS    OF    DIET 

habit.  If  Chittenden  is  right,  then  all  the  world,  with 
the  exception,  perhaps,  of  a  few  supposed  faddists,  has  been 
wrong.  The  nutrition  of  man  involves  an  intelligent 
appreciation  of  the  needs  of  the  body,  under  different 
conditions  of  existence,  and  constant  modification  and 
adaptation  to  changing  environment,  and  states  of  age, 
occupation,  and  health.  Science  has  certainly  not  spoken 
her  last  word  respecting  it,  but  deep  down  beneath  all 
superficial  changes  and  gradual  evolutions,  there  are  certain 
fundamental  nutritional  demands  that  cannot  be  varied 
without  risk.  These  are  embodied  in  ancient  traditions 
and  customs,  and  one  of  these  customs  is  the  demand  for  a 
protein  intake  much  more  than  double  what  Chittenden 
says  is  a  sufficiency. 

"The  generalized  food  customs  of  mankind,"  said  the 
late  Sir  William  Roberts,  ' '  are  not  to  be  viewed  as  random 
practices,  adapted  to  please  the  palate  or  gratify  an  idle  or 
vicious  appetite.  These  customs  must  be  regarded  as  the 
outcome  of  profound  instincts  which  correspond  to  certain 
wants  of  the  human  economy.  They  are  the  fruit  of  colossal 
experience  accumulated  by  countless  millions  of  men 
through  successive  generations.  They  have  the  same 
weight  and  significance  as  other  kindred  facts  of  natural 
history,  and  are  fitted  to  yield  to  observation  and  study 
lessons, of  the  highest  scientific  and  practical  value." 

I  have  given  this  viewpoint  a  rather  full  discussion  for 
the  reason  that  so  much  is  just  now  being  written  con- 
cerning dietetics,  and  so  many  fads  are  being  promulgated, 
that  the  unwary  student  is  liable  to  unwittingly  subscribe 
to  some  dietetic  fad  to  the  disadvantage  of  himself  and 
those  who  come  to  him  for  advice. 

The  conclusions  of  Chittenden  cannot  be  lightly  cast 
aside,  but  their  application  to  patients  suffering  from  diges- 
tive disturbances,  especially  where  there  is  any  tendency 
to  malnutrition,  is  fraught  with  danger,  and  should  not 
be  adopted  without  a  weighty  reason  on  the  part  of  the 
physician. 


THE    MIXED    DIET  32 1 

In  health  it  is  a  fairly  safe  rule  to  follow,  that,  provided 
the  individual  partakes  of  a  varied  diet  of  the  generally 
accepted  foods  of  value,  his  supply,  in  so  far  as  their 
quantities  and  character  are  concerned,  may  to  a  great 
extent  be  regulated  by  his  appetite.  Such  articles  should 
be  chosen  that  include  both  animal  and  vegetable  foods, 
and  the  quantities  should  correspond  to  a  certain  extent 
to  the  amount  of  physical  or  other  labor  that  he  performs. 
Regardless  of  all  that  has  been  said  or  written  in  advocacy 
of  certain  unique  dietetic  fads,  like  vegetarianism,  fruitarian- 
ism,  avoidance  of  flesh  proteins,  etc.,  it  may  be  said  that 
in  the  main  a  mixed  diet  affords  the  greatest  amount  of 
health  and  strength,  though  in  some  it  may  not  give  the 
best  results.  It  may  be  also  said  in  a  general  way  that 
most  sufferers  from  indigestion  do  not  err  so  much  in 
variety  as  in  aggregate  quantity  of  food  consumed.  That 
this  is  often  too  high  can  be  proved  by  computing  the  total 
calories  of  the  foods,  and  comparing  their  value  with  the 
amount  of  work  this  person  performs.  In  such  diseased 
conditions  of  the  body  as  uremia,  gout,  obesity,  chronic 
rheumatism,  arterio-sclerosis,  chronic  interstitial  nephritis, 
chronic  myocarditis,  diabetes,  and  similar  conditions,  the 
low  protein  ration  according  to  Chittenden  has  a  range  of 
usefulness;  also  in  the  excessive  putrefactive  changes  in 
the  intestines,  concerning  which  we  are  not  sure,  it  is  well 
to  be  on  the  safe  side  with  the  protein  intake.  If,  however, 
the  body  is  in  a  fair  state  of  health,  and  the  digestive  organs 
seem  to  perform  their  duties  with  no  distress  to  the  in- 
dividual, it  is  a  fairly  safe  rule  to  permit  the  appetite  to 
have  its  sway,  within  reasonable  limits. 

In  illness  of  the  body  in  general,  and  of  the  digestive 
organs  in  particular,  it  is  necessary  that  we  be  more 
definite,  and  this  requires  certain  fixed  dietaries  to  meet 
certain  pathologic  conditions.  In  the  fixing  of  dietaries 
to  meet  diseased  or  incompetent  states  of  the  digestive 
organs,  there  are  many  considerations  involved,  and  it  is 
therefore  imperative  that  we  have  standards  to  go  by, 


32  2  GENERAL   CONSIDEEATIONS    OF   DIET 

even  though  some  of  those  standards  are  somewhat  arbi- 
trary. These  standards  should  keep  in  view  two  main 
indications — the  maintenance  of  the  body  heat  without 
depriving  the  tissues  of  their  component  structure,  and  the 
supplying  of  sufficient  calories  to  meet  the  demands  that 
are  made  upon  the  body  for  manual  or  mental  labor 
(potential  energy).  Certain  other  considerations  depend 
upon  the  climate,  or  even  severe  weather  in  a  temperate 
climate. 

The  supply  of  nutrition  in  the  body  is  derived  from 
physiologic  oxidation  of  the  carbohydrate,  hydrocarbon 
and  protein  contents  of  the  food.  In  the  making  up  of 
dietaries  for  the  sick,  2750  calories  are  about  right  for  a 
man  of  140  pounds,  or  about  100  calories  for  each  5  pounds 
of  body  weight.  Thus,  understanding  the  conditions 
that  are  to  be  met  by  the  designation  and  quantities  of 
food,  their  selection  according  to  the  caloric  method  of 
feeding  is  not  only  scientific  and  easy  of  application,  but  is 
also  practical  and  safe.  In  this  we  are  dealing  with  a  definite 
scale,  like  definite  doses  of  medicine,  which  we  can  keep  at 
an  equilibrium,  decrease,  if  it  be  required,  or  increase  up  to 
the  limit  of  tolerance,  if  it  be  desired  to  crowd  over  the 
normal  physiologic  need  when  it  is  wished  to  add  an  extra 
amount  of  weight,  energy  or  heat. 

For  the  purpose  of  a  definite  start  in  the  construction  of 
dietaries,  some  standard  must  be  accepted  as  the  proper 
amount  of  food  components  best  suited  to  the  needs  of 
the  body,  and  in  the  main,  the  dietaries  given  here  will 
approximate  in  value  the  requirements  as  indicated  by 
Rubner.  In  his  classic  experiments  with  foods  that 
were  oxidized  outside  the  living  body  in  the  calorimeter, 
he  proved  that  the  oxidation  of  the  same  foods  in  the 
living  body  produced  practically  the  same  amount  of 
heat.  It  must  be  remembered  in  this  connection  that  a 
portion  of  food  is  lost  to  the  general  body,  not  being 
utilized,  and  escaping  with  the  feces.  This  on  a  mixed  diet 
may  be  estimated  as  8  per  cent.,  and  this  allowance  must 


CALORIC   REQUIREMENTS  323 

be  made  in  reckoning  the  needed  supply  of  calories  in  a 
diet  list. 

While  many  of  the  published  experiments  deal  in  the 
small  calories,  it  is  better  in  making  up  diet  lists  to  employ 
the  large  calories,  and  in  addition  to  build  up  a  scale  upon 
the  basis  of  5  pounds  of  body  weight  requiring  100  calories 
daily. 

The  average  quantities  of  foods  required  daily  by  a  man 
weighing  140  pounds  would  be,  according  to  Rubner: 

At  rest 2303 

At  slight  manual  labor 2445 

At  moderate  manual  labor 2668 

At  hard  manual  labor 3662 

This  cannot  be  taken  as  an  absolute  standard,  because 
there  is  no  one  schedule  that  would  properly  fit  all  in- 
dividuals, even  of  the  same  weight  and  amount  of  physical 
exertion  daily.  In  a  general  way  it  may  be  stated  that  in 
ordinary  work  between  2500  and  3300  calories  would 
adequately  supply  a  140-pound  man,  and  that,  on  a  diet 
containing  more  than  that  number  of  calories,  he  should 
be  reasonably  expected  to  improve  in  nutrition,  strength, 
and  weight. 

The  diet  being  established,  and  being  strictly  followed 
by  the  patient,  the  practical  means  of  ascertaining  its 
success  is  by  means  of  the  frequent  use  of  the  scales  for 
the  first  two  weeks.  While  it  is,  of  course,  wise  to  note 
any  feelings  of  weakness,  faintness,  or  hunger  that  may  be 
complained  of  by  the  patient,  they  need  not  cause  any 
great  apprehension  if  the  weight  is  steadily  increasing,  the 
heart  action  is  good,  and  the  general  appearance  of  the 
individual,  as  seen  through  the  practised  eyes  of  the 
physician,  is,  favorable. 

Furthermore,  it  is  of  great  assistance  in  carrying  out  the 
dietetic  regulations  so  as  to  enable  the  patient  to  consume 
with  ease  the  requisite  amount,  that  attention  be  paid 
to    arranging    a    dietary    pleasing    to    the    appetite.     By 


324  GENERAL   CONSIDERATIONS    OF   DIET 

this  means  the  beneficent  influence  of  the  hormones  are 
brought  into  action,  the  various  psychic  aids  are  uncon- 
sciously enlisted,  while  the  food-stuffs  will  be  eaten  with 
more  pleasure  and  be  more  thoroughly  oxidized. 

Because  of  the  compensatory  functions  of  the  alimentary 
canal  in  its  different  parts  toward  various  foods,  it  is  not 
conducive  to  the  best  results  to  build  up  the  diet  list  on 
the  supposed  periods  at  which  certain  foods  leave  the 
stomach.  There  are  so  many  influences  that  modify  the 
exit  of  foods  through  the  pylorus,  that  a  calculation  along 
this  line  should  not  enter  much  in  the  building  of  a  dietary. 
This  phase  of  the  subject  of  nutrition  should  be  considered 
in  connection  with  abnormal  local  conditions  or  symptoms, 
and  when  the  medical  attendant  is  attempting  to  better 
noiu-ish  the  whole  body,  it  is  generally  safe  to  depend  upon 
the  compensatory  power  of  the  small  intestine  to  make  up 
for  most  deficiencies  in  the  saliva  or  gastric  juice. 

The  following  table,  modified  from  that  of  Koenig  and 
others,  gives  the  chemic  compositions  of  most  of  the 
,  foods  used  and  the  heat  units  they  produce.  More  com- 
plete tables  can  be  obtained,  if  desired  by  application  to 
the  United  States  Department  of  Agriculture  at  Wash- 
ington, D.  C. 


COMPOSITION   OF   FOODS 


325 


CHEMIC  COMPOSITION  OF  COMMON  FOOD  SUBSTANCES 
I.  Meats  and  Game 


Per  cent. 

nitrogenous 

(proteid) 


Per  cent, 
fat 


Per  cent, 
carbohydrate!      Calories 
(nitrogen  per  100 

free)         | 


Beef  (very  fat) 

Beef  (lean) 

Veal  (fat) 

Veal  (lean) 

Mutton  (fat) 

Mutton  (lean) 

Pork  (fat) 

Pork  (lean) . . 

Westphalia  ham.  .  .  . 

Salted  ham 

Smoked  beef 

Smoked  beef  tongue. 
Pulverized  meat.  .  .  . 

Sweetbread 

Chicken  (fat) 

Chicken  (lean) 

Capon 

Duck  (wild) 

Partridge 

Pigeon 

Hare 

Venison 


17.19 
20.78 
18.88 
19.84 
14.80 
17.  II 

14-54 
20.25 

23 -97 
22.32 

2"]  .  10 

24-31 

64-5 

22.0 

18.49 

19.72 

23-32 

22.65 

25.26 

22.  14 

23 -34 

19.77 


26.38 
1.50 
7.41 
0.82 

36.39 

5-77 

37-34 

6.81 

36.48 
8.68 

15-35 
31-61 

5-24 
0.4 

9-34 
1.42 


0.07 


0.05 


1.50 


2.28 


15 
,  II 

•43 
,00 

•13 
,92 


1.20 

1 .27 
2.49 
2.33 


0.76 
o.  19 
1.42 


315-81 

99-15 

146.61 

86.97 

399-31 
123.81 
406.88 
146.36 
453  69 
173-23 
253-76 
393-64 
322.53 

93-92 
167.58 

99.10 

135-II 
131-36 
116.85 
100.02 
107.08 
105.44 


II.  Fish 


Per  cent, 
nitrogenous 
(proteid)   • 

Per  cent, 
fat 

Per  cent, 
carbohydrate 
(nitrogen  free) 

Calories 
per  100 

Eel 

12.83 

18.34 
20.61 
17.09 
11.94 
15.01 
22.30 

4-95 
10.  II 
18.90 
31-36 

28.37 
0.51 
1.09 

9-34 
0.25 
6.42 
2.21 

0.37 

7. II 

16.89 

15-61 

0.53 
0.63 

312.93 
83-57 
94-64 

156.93 

Z1     fifi 

Pike 

Carp 

Shellfish 

Halibut 

0   A^ 

Salmon 

2.85            i          132.93 

0     4.=;                              TT-J     9.1 

Sardellen 

Oysters 

2.62 

- -0  - ^0 
34-39 
106.15 
247.61 
279.76 

Fresh  herring 

Salt  herring 

Caviar 

1-57 

2.23 

326 


GENERAL   CONSIDERATIONS    OF   DIET 
III.  Dairy  Products 


Per  cent. 

nitrogenous 

(proteid) 


Per  cent. 

fat 


Per  cent, 
carbohydrate 
(nitrogen  free) 


Calories 
per  100 


Cows'  milk. .  .  . 

Cream 

Buttermilk. . . . 

Whey 

Kumyss  (cows' 
milk). 

Butter 

Cheese  (cream) 

Cheese 

Eggs  (hens')... 
White  of  egg.  . 
Yolk  of  egg  .  .  . 


3.41  to4.3 

3.61 
3.0    to  4 .  o 

0.85 

3-65 


0.5 
16.28 

34-99 
12.5 
12.67 
16.24 


3 .  o  to  3 . 8 
26.75 

0.93  to  1.3 

0.23 

2.07 


90.0 
41 .22 

11-37 
12. 1 
0.25 
31-75 


3.7    to4.8i 

3-52 
3.0    to  4 .  o 

3-03 

Lactic  acid,  0.7; 
alcohol,  1.9; 
carbonic  acid,  8 

0.5 
1 .90 

5-40 
0.5 


56.41  to  71.93 
276.01 

33.08  to  43.63 
18.0 
32.99 


823.1 

449  -  54 
269.06 
165.0 

54-22 

355-99 


IV.   Cereals  and  Vegetables 


Per  cent. 

nitrogenous 

(proteid) 


Per  cent, 
fat 


Per  cent, 
carbohydrate 
(nitrogen  free) 


Calories 
per  100 


Wheat  bread. .  . 

Rye  bread 

Sago 

Wheat  flour. ... 
Rye  flour ...... 

Cakes 

Roll 

Zwieback 

Cauliflower 

Potatoes , 

Asparagus 

Carrots , 

Rice 

Beans 

Peas 

Spinach 

Oatmeal 

Barley  meal. . .  . 
Brussels  sprouts 
Cabbage  (white) 
Pickles 


6.0 
6. II 
0.5 

8.5 
10. o 
II  .0 

6.82 
9.5  to  13.0 

2.0  to    5.0 

1-5 

2.0 

1.04 

5-5 
19-5 
19-5 

2.49 
12.05 

8.31 

4-83 

1.89 

1 .02 


0.75 
0-43 

traces 

1-25 
2.0 
4.60 
0.77 
I. o  to  3.0 

0.4 


0-3 
0.21 

1-5 

2.0 

2.0 

0.58 

5.26 

0.81 

0.41 

0.20 

0.09 


52.0 

46.0 

86.5 

73-0 

69.0 

73-30 

43-72 

75-0 

4-0 
20.0 

2.5 

6.74 
76.0 
52.0 
54-0 

4-44 
66.77 
75-19 

6.22 

4-87 
0.95 


245.0 

217.56 

356.70 

345-78 

342  -  50 

387.09 

213.87 

356.0 

(average) 

350 

88.0 

20.0 

33-85 
348.10 

311-75 

319-95 

33-67 

338.80 

323-0 
49-05 
29-52 
8.81 


COMPOSITION   OF   FOODS 
V.  Soups  and  Beverages 


327 


Per  cent. 

nitrogenous 

proteid 


Per  cent, 
fat 


Per  cent,  non- 
nitrogenous 
carbohydrate 


Calories 
per  100 


Meat  broth 

Meat  juice  (expressed). 

Beef-tea 

Leube's   meat   solution 

Malt  extract 

Milk  soup  with  wheat 
flour. 

Barley  soup 

Rice  pap  with  milk . . . 

Coffee 

Tea 

Beer 

Porter 


0.4 
6.0  to    7.0 

0.5 

9  to  II  albu- 
men and  1.7 
to  6.5  pepton 
8.0  to  10. o 
50 

1-5 
8.8 
312 
12.38 
0.5 
0.7 


0.6 
0.5 

0.5 


3-25 

i.o 

3-5 
5.18 


525 
6.0 


0.5 


550 
15.0 

II  .0 
28.6 


0.3 
0.3 


7. 10 
31.20 

(average) 
6.6 

86.5 
(average) 

258.30 
112. o 

60.96 
182.61 
59  92 
50.75 
51.0 
60.0 


VI.  Fruits,  Nuts,  and  Sugar 


T^  ^      Per  cent. 

Per  cent. 

,  .  1  nitrogenous 

free  acid  °    . , 

proteid 


Per  cent, 
fat 


Chiefly  sugar 


Per  cent,  non- 
nitrogenous 
carbohydrate 


Calories 
per  100 


Apples 

Pears 

Plums 

Peaches 

Apricots 

Grapes 

Strawberries. . 
Chestnuts. .  .  . 
Cane-sugar. . . 
Beet-sugar.. . . 
Honey 


0.82 
0.20 
1.50 
0.92 
1. 16 
0.79 
0.93 


5-48 
0.35 


0.45 
1-37 


7.22 
8.24 
4.68 

7.17 
4.69 
14.36 
6.78 
38.34 
93-33 
99-75 
73.22 


29.6 

33-78 

19.18 

29-39 
19.22 

58.87 

31-88 

192. II 

382.65 

408.97 
305.22 


328  GENERAL    CONSIDERATIONS    OF   DIET 

I.  A  Chiefly  Milk  Diet  with  Addition  of  Carbohydrates  in  Liquid  Form 


Albumen 
(per  cent.) 

Fat 
(per  cent.) 

Carbohydrate 
(per    cent.) 

Calories 
per  100 

Milk,  1700  cc 

70.2 
10. 0 

7.0 

66.3 

69.7 
30.0 

40.0 

1295 
164 

244 

Soup  of  tapioca  flour,  30 

gm.  and  10  gm.  albumosei 

Soup  of  40  gm.  wheat  flour, 

with   some   of   the   milk, 

10  gm.  sugar,  and  one  egg. 

5-5 

Total 

87.2 

71.8 

139-7 

1703 

II.  A  Diet  Rich  in  Proteins 

Breakfast. — Corned-beef  hash,  oatmeal,  toast,  eggs,  bread  and  butter,  coffee 
or  tea,  and  milk. 

Dinner. — Soup,  roast  beef,  potatoes,  rice,  turnips,  toast,  pudding  and  milk, 
bread  and  butter. 

Supper. — Cold  roast  beef  or  pressed  corned  beef,  bread  and  butter,  coffee 
or  tea,  and  milk. 


III.  A  Chiefly  Milk  Diet  with  the  Addition  of  Carbohydrates  and  Fat  in  Mushes 

and  Soups 


Albumen 

Fat 

Carbohydrates 

Calories 

(per  cent.) 

(per  cent.) 

(per  cent.) 

per  100 

Good  milk,  1500  cc 

62 

58.5 

63 

1056 

Soup  of  15  gm.  sago,  10  gm. 

17 

13-5 

15 

257 

butter,  I  egg,  10  gm.  al- 

bumose. 

Pap  of  80  gm.  corn  flour, 

7 

5-5 

90 

398 

I  egg,  10  gm.  sugar  (two 

meals). 

Total 

86 

77-5 

168 

1711 

^  Ten  gm  albumose  is  contained  in  90  cc.  (3  ounces)  of  Denayer's  peptone 
preparation,  in  22  gm.  (5vss)  of  Kemmerich's,  or  in  30  gm.  (i  ounce)  of 
Koch's. 


DIET    IN    DIGESTIVE    DISORDERS 


329 


VI.  Milk  Diet  with  Addition  of  Solid  Food,  Pastry, 

and  Broths,  leaving  little 

Residue 

Albumen 

Fat 

Carbohydrates 

Calories 

(per  cent.) 

(per  cent.) 

(per    cent.) 

per  100 

Milk,  1250  cc 

51 

49 
14 

52 

878 

Meat  broth  with  i  egg,  10 

10 

30 

294 

gm.  of  butter,  50  gm.  of 

fine  toasted  wheat  bread 

(or  softened). 

Cakes   70  gm.,   butter   15 

5 

12 

50 

337 

gm. 

Soup    of    30    gm.    tapioca 

7 

14 

30 

282 

flour,  I  egg,  10  gm.  butter. 

Total 

73 

89 

162 

1 79 1 

Diet  in  Digestive  Disorders.— In  considering  the  feeding 
of  those  suffering  from  gastrointestinal  disorders,  and  in 
constructing  a  rational  dietary,  there  must  be  taken  into 
account  the  advancing,  lowering,  or  level  maintainance  of 
their  nutrition,  supplying  the  proper  number  of  calories 
to  furnish  heat  and  energy  commensurate  with  the  patho- 
logic state,  and  at  the  same  time  so  regulate  the  character 
of  the  nourishment  ingested  as  to  meet,  without  irritation  or 
disturbance,  the  disordered  powers  of  digestion.  Some- 
times, when  the  body  as  a  whole  is  far  below  par  in  nutri- 
tion, or  when  there  are  specific  demands  for  certain  food 
elements,  it  is  allowable  to  disregard  the  disturbed  gastric 
digestion,  paying  the  most  attention  to  strengthening  of  the 
body  as  a  whole.  On  the  other  hand,  there  may  be  present 
certain  abnormal  conditions  of  the  digestive  organs, 
which  if  disregarded,  will  prevent  recovery,  and  perhaps, 
by  failure  of  digestion,  will  cause  the  undigested  food  to  act 
as  a  foreign  body,  not  only  increasing  local  disorder,  but 
also  provoking  general  harm.  As  examples  of  this  may  be 
mentioned  the  errors  of  gastric  and  small  intestine  digestion, 
causing  decreased  secretions  in  these  organs  (such  as  organic 
disease  of  the  glandulature  of  the  stomach,  pancreas,  and 


33°  GENERAL   CONSIDERATIONS   OF  DIET 

small  intestine),  where  there  is  much  toxogenic  decom- 
position of  the  proteins  and  fats  due  to  bacteria  in  the  canal, 
or  where  the  albumen  loss  of  the  whole  food  is  constantly- 
great. 

In  the  construction  of  a  dietary  to  meet  abnormal  condi- 
tions of  the  digestive  tract,  especially  in  the  presence  of 
emaciation  or  lowered  states  of  nutrition,  I  wish  to  warn 
my  readers  not  "hew  to  the  line"  too  closely,  for  if  a 
mistake  is  made,  it  will  be  better  for  the  patient  to  make  it 
on  the  side  of  too  much  food  than  too  little;  and  in  this 
connection  I  wish  to  reiterate  the  statement  previously 
made  that  I  have  seen  many  patients  brought  to  a  danger- 
ous state  of  malnutrition  by  an  unwisely  restricted  diet, 
even  though  such  a  diet  may  have  been  logically  indicated 
by  local  or  general  disease. 

It  might  be  well  also  to  remind  the  reader  of  the  fact  that 
proteins  may  be  markedly  increased,  yet  the  quota  of  cir- 
culating proteins  be  maintained  by  the  carbohydrates,  and 
that  these,  under  conditions  of  good  starch  digestion,  can 
be  considerably  increased  without  the  causing  of  local  dis- 
tress ;  and  further  that  the  entire  canal  is  decidedly  compen- 
satory in  its  digestive  power  to  all  distinct  food  substances. 

When  digestion  in  the  stomach  is  slow,  as  in  the  primary 
atonies,  pylorospasm,  nervous  hypermotility,  chronic  gas- 
tritis, or  pyloric  stenosis,  it  is  well  to  select  such  foods  that 
require  but  little  from  the  stomach  proper,  but  quickly 
pass  out  of  it.  By  so  doing,  we  prevent  to  a  degree  sub- 
jective distress,  check  the  tendency  to  gastric  fermentation 
or  stagnation,  and  directly  assist  in  systemic  nutrition. 

The  following  table  from  Penzoldt  gives  a  fairly  good 
idea  of  the  time  that  definite  quantities  of  various  foods  leave 
the  stomach  in  health.  As  all  fluids  pass  through  the 
stomach  quickly,  they  have  not  been  included.  It  might 
be  well,  however,  to  mention  that  later  physiologic  experi- 
ments show  that  the  presence  of  fats  have  a  decided  in- 
fluence in  delaying  evacuation,  and  that  in  hypermotility, 
the  addition  of  a  rather  large  content  of  fats  will  prevent  the 


penzoldt's  tables  331 

carbohydrates  and  proteins  from  leaving  the  stomach  too 
quickly. 

PENZOLDT'S  TABLES 

From  one  to  two  hours: 

100  to  200  grams  of  milk,  boiled. 

200  grams  meat  broth  (no  addition). 

100  grams  eggs,  soft. 

200  grams  beer. 
From  two  to  three  hours : 

200  grams  cocoa  with  milk. 

200  grams  light  wines. 

400  grams  beer. 

300  to  500  grams  milk,  boiled. 

100  grams  eggs  in  any  style. 

100  grams  beef  sausage,  raw. 

200  grams  fish,  boiled. 
75  grams  oysters. 

150  grams  cauliflower,  boiled. 

150  grams  potatoes,  boiled  or  mashed. 
70  grams  light  bread,  fresh  or  stale. 

50  to  70  grams  biscuit,  zwieback,  or  crackers. 
From  three  to  four  hours : 

230  grams  spring  chicken,  partridge,  or  squab,  boiled. 

190  grams  spring  chicken,  partridge,  or  squab,  broiled. 

250  grams  beef,  raw  or  cooked. 

160  grams  ham,  boiled. 

100  grams  roast  veal. 

100  grams  beefsteak,  raw-scraped  or  chopped. 

100  grams  roast  beef. 

200  grams  fish,  boiled. 

150  grams  breads,  biscuit,  cereals,  vegetables  and  fruits. 
From  four  to  five  hours : 

210  grams  squab,  broiled. 

250  fillet  beef,  beefsteak,  broiled. 

250  grams  beef  tongue. 

250  grams  ham,  broiled. 

250  grams  goose,  roasted. 

280    grams  duck,  roasted. 

150  grams  lentils,  puree. 

200  grams  peas,  puree. 

150  grams  string  beans,  boiled. 

The  above  is  lacking  in  many  of  the  foods  ordinarily  eaten, 
but  will  give  a  fair  idea  of  the  time  required  for  most  of 
our  commonly  used  articles  to  leave  the  stomach.     It  is 


332  GENERAL   CONSIDERATIONS    OF   DIET 

often  necessary,  in  cases  where  dietetic  regulations  extend 
over  a  long  period,  to  use  much  igenuity  in  selecting  the 
articles,  for  the  patient  becomes  wearied,  and,  unless 
some  attention  is  paid  to  the  demands  of  the  palate  or 
desires  of  the  appetite,  there  will  not  be  enough  food 
ingested,  and  bodily  malnutrition  supervenes. 

In  pyloric  stenosis,  a  liquid  or  semi-liquid  diet  is  best 
on  account  of  the  difficulty  experienced  by  the  more  solid 
foods  in  passing  through  this  narrowed  channel;  also  in 
hyperesthetic  conditions,  or  post-ulcer  states,  in  order  to 
minimize  irritation  from  the  presence  of  foods;  or  in 
prolonged  gastric  digestion  in  the  presence  of  ulcer,  mul- 
tiple erosions,  gastrorrhagia,  etc.,  the  patient  should  be 
placed  upon  a  liquid  diet  for  a  while  at  least. 

There  is  still  some  divergence  of  opinion  concerning  the 
proper  diet  in  hypersecretion  of  gastric  juice.  In  hyper- 
chlorhydria,  some  advocate  a  high  protein  diet  to  bind 
the  acid,  while  others  recommend  a  bland  carbohydrate 
regimen  to  both  bind  and  eventually  control  its  formation. 
This  question  cannot  be  settled  by  any  hard  and  fast 
rule,  but  modifying  conditions  must  be  taken  into  ac- 
count, such  as  the  amount  of  mucus,  the  enzymotic  power 
present  in  the  gastric  juice,  the  present  state  of  nutrition 
of  the  patient,  and  the  facts  pertaining  to  the  healing  of 
•  gastric,  duodenal  ulcers,  etc. 

A  very  good  general  rule,  as  employed  by  Bassler,  is  as 
follows:  Where  the  acid  is  higher  than  the  amount  of 
enzymes,  the  use  of  a  high  flesh  protein  diet  is  worthy  of 
attention,  and  is  often  beneficial  to  the  patient.  Care 
must  be  exercised,  however,  that  in  our  efforts  to  bind 
the  extra  acid,  we  do  not  stimulate  the  stomach  to  develop 
more  coaptation  secretion  of  HCL,  and  thus  later  cause 
an  aggravation  of  the  original  disturbance.  In  the  working 
up  of  the  diet  to  a  safe  meeting  point  to  the  acid,  it  is  well 
to  employ  the  heavier  vegetable  proteins,  though  the 
animal  proteins  should  form  the  main  stay  to  just  short 
of  the  enzymotic  content.     But  when  there  is  but  little 


DIET    IN    HYPERCHLORHYDEIA  333 

mucus  in  the  stomach,  and  the  acid  content  deficient,  a 
diet  mixed  in  variety,  but  with  a  heavier  proportion  of  the 
vegetable  proteins,  will  generally  afford  better  results 
eventually. 

With  uncomplicated  hyperchlorhydria  (some  are  doubt- 
ful as  to  this  condition  ever  being  present)  it  is  well  to 
ascertain  whether  the  high  acid  index  is  due  to  a  nervous 
exacerbation  alone,  as  is  seen  in  the  neurotics  of  young 
adult  or  middle  life,  or  whether  it  is  a  well-established 
high  or  continually  running  acidity.  In  the  former  a 
high  protein  diet  to  bind  the  excess  free  acid  for  a  short 
while  is  indicated;  while  in  the  latter  and  more  chronic 
condition,  a  continued  high  protein  diet  prolongs  the 
hyperacidity. 

In  acute  ulcer  of  the  stomach,  each  case  must  be  dieted 
according  to  the  conditions  present.  Where  the  acidity 
is  very  high,  all  irritations,  whether  mechanic,  chemic,  or 
thermic,  must  be  avoided,  and  the  fluid  must  be  bland, 
and  neither  too  hot  nor  cold.  A  milk  and  egg  diet  best 
fulfills  this  requirement.  To  this  may  be  added  later 
vegetables  in  the  form  of  purees,  but  meat  and  other  solid 
foods  are  best  excluded  until  very  late  in  the  course  of  the 
treatment. 

In  the  different  conditions  of  deficient  gastric  secretion, 
as  hypochlorhydria,  achylia  gastrica,  and  atrophic  gastritis, 
it  is  advisable  to  control  the  amount  of  total  proteins,  and 
sustain  nutrition  more  with  carbohydrates  and  fats.  Meats 
should  not  be  excluded  altogether,  because,  if  they  are 
finely  cut  up  or  well  masticated,  the  intestines,  in  their 
compensatory  function,  will  take  care  of  them. 

In  the  sensory  disturbances  of  the  stomach,  much 
depends  upon  whether  they  are  primary  in  that  organ  or 
secondary  to  neurotic  conditions  elsewhere  in  the  body. 
In  the  primary  type,  which,  as  I  have  said,  many  doubt 
(gastralgia,  or  local  hyperesthesia)  light  and  bland  food, 
free  from  chemic  or  thermic  irritation  should  be  enjoined; 
also  there  should  be  a  prohibition  as  to  carbonated  drinks, 


334  GENERAL   CONSIDERATIONS    OF   DIET 

alcoholic  stimulants,  and  highly  seasoned  foods.  Where 
the  condition  is  apparently  set  up  by  reflexes  from  other 
organs,  for  instance,  the  crises  of  locomotor  ataxia,  or 
cyclic  vomiting,  the  same  rule  holds  good  in  pronounced 
cases,  though  the  general  state  of  the  body  should  be  taken 
into  consideration,  and  a  diet  as  nourishing  as  possible 
should  be  recommended. 

Mastication. — The  chewing  of  our  food  is  a  subject  of 
more  or  less  interest  to  us  all.  Beginning  with  precepts 
inculcated  in  every  nursery,  we  are  constantly  admonished 
throughout  life  that  thorough  mastication  is  a  prerequisite 
to  health ;  while  a  rather  recent  school  of  thought  contends 
that  the  whole  process  of  bodily  nutrition  is  markedly 
affected  by  the  preliminary  treatment  of  food  in  the  mouth. 

Mastication  is  an  entirely  voluntary  act,  while  the  per- 
formance of  swallowing  is  a  complicated  reflex  movement, 
initiated  voluntarily,  but  for  the  most  part  completed 
independently  of  the  will.  Under  normal  conditions  the 
presence  of  moist  food  on  the  tongue  seems  essential  to 
the  completion  of  this  act,  and  I  might  add  that  a  pleasant 
taste,  coupled  with  a  favorable  mental  attitude,  still 
further  facilitates  the  passage  of  food  down  the  esophagus. 

Too  rapid  eating,  or  tachyphagia,  is  a  frequent  fault, 
and  has  no  doubt  caused  many  digestive  qualms,  besides 
being  the  starting-point  of  many  chronic  disorders  of  the 
alimentary  tract.  This  I  admit,  but  do  not  admit  the 
necessity  for  slow,  deliberate  and  systematic  mastication 
as  a  sine  qua  non  for  health  in  every  individual,  irrespective 
of  temperament  or  station  in  life;  nor  do  I  believe  it  con- 
ducive to  the  best  work  of  the  digestive  organs  that  a  hard- 
and-fast  rule  be  enjoined,  whereby  a  certain  stated  period 
must  be  devoted  to  the  mastication  of  a  meal,  regardless 
of  the  pleasure  or  inclination  of  the  person. 

From  time  to  time  apostles  of  deliberate  mastication,  or 
bradyphagia,  have  appeared  on  the  horizon,  the  most 
prominent  of  these  being  Mr.  Horace  Fletcher,  whose  work 
"the  a.  b.  c.  of  our  nutrition,"  is  so  largely  devoted 


MASTICATION   AND   INSALIVATION  335 

to  this  topic,  and  who  so  well  pleads  its  cause,  that  slow 
and  continuous  mastication  and  insalivation  until  the 
food  is  liquefied  in  the  mouth  and  almost  imperceptibly 
swallowed,  is  called  "Fletcherism." 

The  history  of  Mr.  Fletcher  and  his  movement  is  known 
to  most  of  my  readers,  and  need  not  be  repeated  here, 
but  in  regard  to  his  doctrines  in  general  I  wish  to  enter  a 
note  of  protest. 

Concerning  the  protein  constituents  of  food,  insalivation 
exerts  but  little  effect.  We  well  know  that  either  the  pepsin 
and  hydrochloric  acid  in  the  stomach  or  the  trypsin  beyond 
will  attend  to  them,  if  they  are  decently  comminuted,  and 
their  stay  in  the  mouth  need  be  only  long  enough  to 
originate  those  psychic  impulses  which  Pavlov  has  shown 
us  regulate  the  subsequent  flow  of  digestive  juices.  Car- 
nivorous animals  habitually  bolt  their  food,  and  zoologic 
history  shows  that  they  come  to  no  harm  thereby.  The 
essence  of  salivary  digestion  is  the  transformation  of  starch 
into  sugar  by  the  action  of  the  ptyalin,  and  that  process, 
though  inaugurated  in  the  mouth,  continues  until  the 
whole  of  the  stomach  contents  become  acid.  The  time  of 
salivary  digestion  is  brief,  and  to  be  effectual  should  be 
energetic.  No  more  should  be  expected  of  it  than  a  pre- 
liminary act.  The  pancreas  and  other  juices  beyond 
the  stomach  will  care  for  the  starches,  if  only  the  psychic 
centers  forward  the  proper  impulses  as  received  by  the 
gustatory  senses. 

As  to  the  method  or  comparative  rapidity  of  chewing,  I 
might  say,  and  say  correctly,  it  is  to  a  great  extent  tem- 
peramental. As  some  people  can  perform  a  stated  task, 
and  perform  it  well,  in  half  the  time  required  by  slow- 
moving  individuals;  and  as  some  people  move  quickly, 
speak  quickly,  and  think  quickly,  so  they  also  chew  quickly, 
but  well.  By  those  ardent  and  strenuous  spirits  who  are 
happiest  when  in  the  busy  turmoil  of  competitive  struggle, 
the  act  of  mastication  is  performed  briskly,  but  none  the 
less  adequately.     To  that  other  class,  who  desire  to  meander 


336  GENERAL   CONSIDERATIONS    OF   DIET 

through  Ufe  in  a  leisurely  way,  or  to  those  semi-valetudi- 
narians whose  gastronomic  powers  are  under  constant 
mental  scrutiny,  Fletcherism  comes  as  the  promised  foun- 
tain of  youth. 

Another  objection  to  interminable  mastication  is  the 
brevity  of  life.  In  one  place  Mr.  Fletcher  relates  that  one- 
fifth  of  an  ounce  of  a  young  onion  required  722  chews  before 
it  disappeared  through  involuntary  swallowing,  and  Dr. 
Kellogg  mentions  a  patient  who  cheerfully  spent  never 
less  than  an  hour  and  a  half  in  masticating  his  one  small 
daily  meal.  To  insist  that  busy  men,  those  whose  shoulders 
and  minds  bear  the  burdens  and  cares  of  government, 
commerce  or  literature;  whose  eager  intellects  are  con- 
quering the  earth,  the  sea  and  the  air — to  insist  that  these 
should  be  subjected  to  a  wearisome  mastication  of  in- 
animate food,  is  a  delusion  and  a  snare,  an  anachronism 
in  our  twentieth-century  civilization,  and  a  frittering  away 
of  priceless  time. 

A  certain  amount  of  necessary  chewing  is  advisable,  as 
evidenced  by  the  conformation  of  the  human  teeth.  If 
the  chemic  functions  of  the  stomach  are  deficient,  or  if  the 
outlet  is  greatly  constricted,  fine  mastication  and  thorough 
insalivation  are  highly  beneficial.  To  the  great  majority 
of  every-day  Americans,  however,  a  simple  injunction  as 
to  good  teeth  and  ample  mastication  is  entirely  sufficient, 
and  the  magnification  of  any  division  of  the  digestive 
organs  at  the  expnse  of  another  will  nearly  always  result 
in  direct  or  indirect  harm. 

ARTIFICIAL  FOODS 

By  the  term  artificial  foods  is  meant  the  proprietary  or 
patented  foods  that  are  employed  for  feeding  the  sick  or 
undernourished.  They  comprise  many  forms,  dry,  liquid, 
alcoholic,  etc.,  and  are  recommended  for  those  who  are 
for  any  reason  not  able  to  partake  of  regular  substantial 
foods;    for   irritable    stomachs,    or    severe    vomiting;    for 


ARTIFICIAL   FOODS  337 

administering  proteins,  carbohydrates,  or  fats  in  a  con- 
centrated or  easily  digestible  form;  and  as  a  supplemental 
form  of  alimentation. 

The  Council  on  Pharmacy  and  Chemistry  of  the  Ameri- 
can Medical  Association,  in  its  reports  has  done  much  to 
dispel  the  glamor  thrown  about  some  of  the  alcoholic 
proprietary  food  as  well  as  the  dry  foods,  which  have  been 
placed  upon  the  market  with  such  misleading  claims. 

Its  report  concerning  a  number  of  these  predigested 
foods  is  as  follows : 

"In  order  to  get  a  fair  conception  of  the  actual  value  of 
these  various  preparations,  it  is  desirable  to  make  some 
comparison  which  can  be  readily  understood  by  every 
physician.  The  amount  of  good  milk  necessary  each 
twenty -four  hours  to  sustain  the  vitality  of  a  patient  during 
a  serious  illness  is  not  less  than  64  ounces,  or  approximately 
2000  c.c.  The  food  value  in  calories  represented  in  this 
amount  of  good  milk  may  be  placed  at  1430  calories. 
This  includes  not  only  the  protein  and  carbohydrate  matter, 
but  the  fat  as  well.  By  comparing  the  available  potential 
energy  with  the  total  energy  of  the  predigested  foods  under 
consideration,  it  can  be  readily  seen  that  if  a  physician 
depends  upon  the  representations  made  by  manufacturers, 
and  feeds  his  patients  accordingly,  he  is  resorting  to  a 
starvation'  diet.  The  largest  number  of  available  calories, 
including  alcohol,  present  in  any  of  the  recommended 
daily  doses,  is  less  than  one-fifth  of  the  number  of  calories 
represented  by  2000  c.c.  of  milk;  and  the  calories  repre- 
sented by  the  daily  dose  of  the  preparations  poorest  in 
food  products  is  only  one-twenty-fifth  of  the  amount 
present  in  2000  c.c.  of  milk.  These  figures  tell  their  own 
story.  Making  2000  c.c.  of  milk  the  basis  of  calculation, 
and  estimating  the  amount  of  the  various  preparations 
required  to  yield  this  number  of  calories,  it  is  found  that 
the  quantity  to  be  administered  daily  to  supply  1430  calo- 
ries, including  alcohol,  varies  from  7162  to  1506.2  c.c. 
In  other  words  it  will  be  necessary  in  order  to  supply 


338  GENERAL   CONSIDERATIONS   OF  DIET 

1430  units  of  energy  per  diem,  to  administer  the  amount 
of  the  various  products  in  quantities  found  within  the  above 
limits.  In  many  cases  the  amount  of  alcohol  exhibited 
by  these  quantities  would  keep  the  patient  in  an  alcoholic 
stupor  continually.  The  cost  necessary  to  supply  this  energy 
varies  from  $1.48  to  $3.39.  Compare  these  prices  with  the 
2  quarts  of  milk.     Is  further  comment  necessary?" 

The  dry  proprietary  foods,  too,  in  adequate  quantities 
will  often  disturb  the  digestion  more  than  the  ordinary 
wholesome  foods,  while  the  caloric  value  claimed  for  them 
is  unreasonable.  Dr.  David  Edsall  recently  weighed  a 
specimen  of  one  of  these  dry  foods,  and  reported  that  if 
all  its  weight  were  nutritive  material  (a  liberal  estimate), 
it  was  so  light  that  it  would  take  $1.25  to  $1.50  to  buy 
an  amount  equal  in  food  value  to  a  five-cent  loaf  of  bread. 

Dr.  John  Rowland  in  a  late  paper  on  proprietary  and 
predigested  foods,  showed  by  calculation  that  two  of 
the  most  representative  and  widely  used  infant  foods 
have  little  more  than  twice  the  value  of  whole  milk,  and  that 
without  the  alcohol  they  contain  the  same  nourishment 
as  milk.  The  dose  of  these  foods  advised  for  a  child  of 
six  months  is  a  teaspoonful  every  four  hours,  which  would 
give  the  infant  the  munificent  equivalent  of  2  ounces  of 
milk  daily!  Dr.  Rowland  further  says:  "Assuming  that 
such  a  food  could  be  ingested  without  grave  gastric,  in- 
testinal or  other  disturbance  in  sufficient  quantity  to 
nourish  a  six-months-old  infant,  it  would  cost  about  a 
dollar  a  day,  and  would,  moreover,  require  the  child  to 
take  in  twenty-four  hours  alcohol  equivalent  to  6  ounces 
of  brandy,  enough  to  terminate  his  short  life  or  keep  him 
in  a  state  of  alcoholic  coma." 

Another  greatly  overrated  class  of  foods  are  the  meat 
juices  (not  meat  extracts),  for  which  fabulous  powers 
have  been  claimed.  Well-expressed  juice  obtained  from 
freshly  chopped  beef  may  contain  a  fair  amount  of  actual 
nourishment  in  the  form  of  coagulable  proteins  and  meat 
bases,  and  is  useful  to  tide  over  emergencies,  or  to  satisfy 


DUODENAL    ALIMENTATION  339 

the  patient  that  he  is  being  fed.  As  to  the  meat  extracts 
alone,  however,  they  are  a  delusion.  To  quote  Dr.  A. 
L.  Benedict,  "A  meat  broth  prepared  at  a  temperature 
above  i6o  F.,  the  coagulation  point  of  albumen,  contains 
salts,  extractives,  which  are  mainly  excrementitious,  and 
a  little  gelatin,  as  well  as  some  melted  fat,  although  the  fat 
is  often  skimmed  off.  In  so  far  as  protein  is  concerned, 
a  meat  tea  made  by  boiling  cannot  be  more  nourishing  than 
egg  tea,  that  is  to  say  the  water  in  which  eggs  are  poached, 
or  in  plain  words,  it  contains  no  protein  nouishment  at  all, 
and  is,  barring  certain  qualitative  and  quantitative  differ- 
ences, of  the  same  dietetic  value  as  urine." 

On  such  a  regimen  the  patient  may  be  fairly  water- 
logged with  soup,  and  still  get  less  than  a  hundred  calories 
daily.  If  strength  holds  up  under  such  feeding,  it  is 
from  the  reserve  protein  and  fat  stored  in  the  body,  and 
not  from  any  decided  nutritive  virtue  in  the  soup.  Let 
me  insist,  therefore,  that  the  caloric  requirements  be  either 
met  with  the  well-known  substantial  foods,  or  the  artificial 
foods,  when  given,  be  calculated  at  their  proper  value,  and 
not  by  excessive  estimates  made  by  interested  parties. 
There  are  some  proprietary  foods  that  are  useful,  non- 
irritating  and  convenient  to  administer.  They  should  be 
used  with  discretion,  and  not  blindly,  lest  the  patient  be 
brought  to  a  dangerous  state  of  malnutrition,  as  I  have 
witnessed  in  not  a  few  instances. 

DUODENAL  ALIMENTATION 

Duodenal  alimentation  means  feeding  the  patient  directly 
into  the  duodenum  in  such  a  manner  that  the  stomach 
is  kept  empty.  This  is  accomplished  by  the  introduction 
of  the  duodenal  tube,  the  method  of  which  has  been  pre- 
viously described.  In  this  manner  we  have  the  patient 
always  ready  for  feeding,  independent  of  his  desire  to  eat 
or  his  aversion  for  food. 

This   method   of   alimentation   was   originated   by^Dr. 


340 


GENERAL   CONSIDERATIONS    OF   DIET 


Max  Einhorn,  and  it  has  been  used  by  him  and  many  others 
with  satisfactory  results  in  properly  selected  cases. 

After  the  tube  has  been  introduced  into  the  intestine, 
it  should  not  be  removed  except  for  cause,  being  securely 


Fig.  69. — The  duodenal  feeding  apparatus,  with  table  support.  A,  tube 
leading  to  syringe;  B,  tube  leading  to  duodenal  pump;  C,  crank;  D,  tube  lead- 
ing to  fluid;  F,  fluid;  G,  glass;  T,  table  support  or  shorter  support.  When 
crank  C  is  turned  parallel  to  A,  fluid  can  be  aspirated  from  the  glass  into  the 
syringe.  When  C  is  moved  .^parallel  to  B,  the  fluid  from  the  syringe  can  be 
emptied  into  the  duodenum.     {Einhorn.) 

fastened  to  either  a  garment  by  a  safety  pin  or  to  the  ear  by 
a  silken  thread  attached  to  the  rubber  tube. 

The  food  is  usually  given  every  two  hours,  eight  feedings 
a  day,  though  the  first  two  or  three  days  it  may  be  wise  to 
limit  the  number  to  seven  or  even  six.  The  standard  food 
is  milk  (7  or  8  ounces),  one  egg,  and  a  tablespoonful  of 
lactose.     Should  the  lactose  cause  diarrhea,  it  should  be 


DUODENAL    ALIMENTATION 


341 


either  lessened  or  omitted.  In  cases  where  the  patient  is 
emaciated,  or  it  is  essential  that  no  loss  of  flesh  ensue,  i  or  2 
drams  of  melted  butter  may  be  added  to  every  feeding. 
Occasionally  a  patient  cannot  stand  the  milk,  being  gener- 
ally those  with  whom  milk  habitually  disagrees.  In  this 
event,  instead  of  milk,  water  with  barley  or  pea  flour  may 
be  substituted.  Whatever  is  fed  to  the  patient  must  be  of 
blood  temperature — neither  cold  nor  hot — and  it  must 
be  given  slowly. 


Fig.  70. — Patient  being  fed  through  the  duodenal  tube.     {Einhorn.) 

Dr.  Einhorn  first  attempted  the  use  of  an  irrigator,  letting 
the  fluid  run  in  by  gravity,  but  this  proved  inconvenient, 
because  the  temperature  could  not  be  well  maintained,  and 
the  flow  was  either  too  quick  or  too  slow.  He  then  devised 
a  syringe  with  a  three-way  stopcock,  and  with  a  little 
table.  With  this  there  is  no  need  of  loosening  the  syringe 
from  the  tube  each  time  the  former  has  to  be  filled,  and 
the  feeding  can  be  made  slow  or  fast  as  wished.  The 
patients  usually  prefer  to  have  it  given  slowly,  for,  'if 
given  quickly  they  often  complain  of  ill- defined  qualms  of 
discomfort.  It  seems  at  first  a  tedious  performance,  but 
most  of  the  patients  learn  to  feed  themselves,  and  they  take 


342  GENERAL   CONSIDERATIONS    OF   DIET 

an  interest  in  thus  occupying  their  time.  It  requires 
twenty  or  more  minutes  for  each  feeding,  and  that  re- 
peated eight  times  daily  gives  them  something  to  do. 

A  few  supplementary  points  in  regard  to  technic  will  not 
be  amiss.  The  tube  is  put  into  the  throat  of  the  patient,  and 
he  swallows  it  with  water.  He  should  not  swallow  too 
quickly,  lest  the  tube  rotate  on  itself,  but  by  swallowing 
deliberately,  the  tube  will  be  taken  straight  into  the 
stomach.  Then,  a  little  later,  Hquid  food  is  given  by  the 
mouth,  and  tests  are  made  from  time  to  time  through  a 
syringe  attached  to  the  tube  to  see  what  can  be  obtained. 
If  the  end  of  the  tube  is  still  in  the  stomach,  an  acid  liquid 
appears  easily  and  quickly  by  aspiration.  If  it  has  passed 
the  pylorus  and  is  well  into  the  duodenum,  the  aspirated 
fluid  comes  only  drop  by  drop,  and  generally  shows  an 
alkaline  reaction,  besides  being  somewhat  stringy.  Another 
point  in  differentiation  is  that  if  we  force  air  in  through  the 
syringe,  the  patient  feels  it  immediately,  if  the  pump  is  in 
the  stomach ;  otherwise,  there  is  less  conscious  sensitiveness 
in  the  duodenum,  and  the  patient  does  not  feel  the  air  at  all. 
In  cases  of  achylia  gastrica,  or  absence  of  gastric  secretion, 
it  is  more  difficult  to  be  sure  that  the  tube  has  entered  the 
duodenum.  As  there  is  no  acid  secretion  in  the  stomach,  it 
is  then  necessary  to  use  different  colored  fluids.  For  in- 
stance, a  patient  who  had  has  no  milk,  but  only  bouillon  or 
tea,  may  be  given  a  white-colored  fluid,  such  as  milk.  If 
we  then  aspirate,  and  obtain  a  fluid  that  is  not  white,  we 
know  that  the  tube  is  beyond  the  stomach.  If  the  patient 
has  had  milk,  we  can  give  him  black  coffee,  or  any  colored 
fluid  that  is  not  white. 

Usually  it  takes  two  or  three  hours  for  the  tube  to  enter 
the  duodenum,  but  in  many  cases  requiring  feeding  there  is 
present  a  pyloric  spasm,  and  then  it  takes  much  longer. 
In  some  cases  I  have  had  to  wait  twenty  or  twenty-four 
hours,  and  Einhorn  reports  a  patient,  in  whom  thirty-six 
hours  was  required.  While  waiting  for  this,  the  patient 
may  be  fed  by  the  mouth  with  liquid  diet,  and  tests  are 


DUODENAL    ALIMENTATION  343 

made  from  time  to  time.  In  cases  of  achylia  gastrica  with 
relaxed  pylorus,  the  tube  may  find  its  way  into  the  duo- 
denum very  quickly — sometimes  in  as  short  a  time  as  five 
or  ten  minutes. 

When  ready  to  feed,  the  temperature  must  be  just  right, 
and  the  food  should  be  invariably  strained,  because  in 
passing  through  such  a  long  fine  tube  any  particles  would 
block  the  tube,  if  precautions  were  not  taken.  Another 
quite  helpful  rule  is  that,  after  each  feeding,  a  little  plain 
water  should  be  thrown  in  and  then  a  little  air,  in  order  to 
keep  the  tube  always  empty.  If  these  preventive  measures 
are  not  taken,  the  tube  becomes  clogged  in  a  day  or  two,  and 
the  tube  has  to  be  taken  out  and  replaced,  with  much 
trouble  to  the  physician  and  inconvenience  to  the  patient. 
While  the  patient  has  the  tube  in,  the  mouth  should  be 
frequently  cleansed  with  some  good  mouth  wash,  for  while 
nothing  is  being  eaten  there  is  nothing  to  keep  the  surface 
of  the  tongue  clean. 

The  tube  is  left  in  during  the  course  of  the  treatment. 
Beside  the  feeding,  the  patient  is  given  a  pint  of  saline  by 
the  duodenal  tube,  and  this  may  be  given  either  through  the 
syringe  or  by  connecting  an  irrigator  to  the  tube.  If  the 
patient  objects  to  this,  it  may  be  given  in  the  rectum  by  the 
Murphy  drop  method,  for  the  bowels  absorb  saline  readily. 

The  weight  of  the  patients  should  be  watched  closely. 
Some  of  them  lose,  not  real  flesh,  but  water,  for  the  nitrogen 
examination  generally  shows  that  under  this  regimen  they 
are  able  to  add  to  their  nitrogen  balance.  It  is  well  to 
make  them  gain  a  little  weight,  but  more  necessary  to  keep 
them  from  losing  it. 

Duodenal  alimentation  keeps  the  stomach  empty,  and 
so  gives  it  perfect  rest.  The  principle  of  rest  is  an  im- 
portant factor  in  curing  disease,  and  this  is  an  ideal  method 
of  accomplishing  it.  Another  point  in  its  favor,  as  claimed 
by  Dr.  Einhorn,  is  the  accomplishment  of  a  change  in  the 
size  of  a  dilated  stomach,  which,  when  rested,  tends  to 
return  to  its  normal  size. 


344  GENERAL    CONSIDERATIONS    OF   DIET 

There  are  several  objections  to  duodenal  feeding,  which 
will  be  mentioned.  The  constant  presence  of  the  tube  acts 
as  a  foreign  body  with  some,  and  the  stomach  becomes 
intolerant  of  it.  Should  the  tube  impinge  against  an  eroded 
or  ulcerated  spot,  the  irritation  produced  will  render  the 
retention  of  the  tube  impracticable.  Again,  there  are 
occasional  cases  in  which  vomiting  sets  up  on  the  introduc- 
tion of  the  tube,  and  does  not  cease  until  it  is  removed. 
Occasionally  the  intestine  seems  intolerant  of  the  feeding, 
but  this  can  generally  be  overcome  by  introducing  the  fluid 
more  slowly. 

The  indications  for  duodenal  alimentation,  as  claimed  by 
its  originator,  are:  First,  ulcerations  of  the  stomach  or 
duodenum.  Second,  a  great  many  cases  of  dilatation  of 
the  stomach,  without  organic  obstruction;  extreme  atony, 
no  matter  whether  there  is  pyloric  spasm  present  or  not. 
Third,  in  cases  where  nutrition  is  difficult,  nervous  vomiting, 
vomiting  of  pregnancy,  etc.  Fourth,  disease  of  the  liver. 
Fifth,  inoperable  cancerous  condition  of  the  stomach  or 
cardia,  where  the  stomach  is  not  closed  up  and  the  duode- 
num can  be  reached.  In  the  last-named  condition,  this 
method  may  bring  a  certain  amount  of  comfort  to  the 
patient. 

There  are  great  possibilities  for  good  in  this  form  of 
alimentation,  and  in  cases  where  the  tube  is  well  borne 
the  results  are  sometimes  most  satisfactory. 

RECTAL  FEEDING 

The  administration  of  food  by  the  rectum  is  a  method 
that  dates  back  into  antiquity.  ^Etius  and  others  men- 
tion it,  and  writers  of  the  middle  ages  refer  to  it,  though 
not  in  satisfactory  terms,  as  they  probably  did  not  obtain 
success  on  account  of  their  imperfect  technic.  Voit  found 
that  a  dog's  rectum  would  not  absorb  egg-albumen  and 
water  unless  sodium  chlorid  were  mixed  with  it. 

Later  von  Leube  advised  the  use  of  albumen  to  which 


RECTAL    ALIMENTATION  345 

chopped  pancreas  had  been  added.  Ewald,  however, 
showed  that  this  was  unnecessary,  and  that  albumen, 
neither  peptonized  nor  pancreatinized,  could  be  absorbed, 
especially  if  a  small  amount  of  salt  was  added.  The 
presence  of  salt  seems  to  cause  reverse  peristalsis,  and 
Grutzner  has  demonstrated  that  substances  introduced 
with  the  salt  solution  may  later  be  found  in  the  stomach. 

Many  varieties  of  food  may  be  utilized  in  rectal  alimen- 
tation. Protein  may  be  supplied  in  the  form  of  predigested 
meat  or  egg-albumen,  to  which  salt  has  been  added.  Of 
the  carbohydrates,  grape-sugar  seems  the  most  available, 
though  not  more  than  6  ounces  of  a  lo  to  20  per  cent, 
solution  should  be  allowed,  as  it  tends  to  provoke  looseness 
of  the  bowels.  Starch  has  been  used  in  many  forms, 
solutions  containing  it  being  readily  digested  and  absorbed. 
Fat  also  may  be  used,  but  not  more  than  1/2  ounce  in  the 
twenty -four  hours  is  advisable.  Such  fats  as  cream  or  oil 
may  be  employed,  but  I  prefer  melted  butter  added  to  the 
enema.  Should  rectal  feeding  be  kept  up  for  some  time, 
it  will  be  best  to  combine  different  articles,  as  well  as  to 
change  the  form  of  administration. 

Bauer  believes  that  but  one-fourth  of  the  nutriment 
required  by  the  body  can  be  absorbed  by  the  rectum,  and 
both  he  and  the  earlier  writers  placed  the  limit  of  time 
during  which  rectal  feeding  was  practicable  at  two  weeks. 
Later  writers  have  placed  the  caloric  absorption  by  the 
rectum  even  lower,  and  it  is  now  a  fairly  well-established 
fact  that  under  ordinary  circumstances  the  rectum  cannot 
be  expected  or  made  to  digest  and  absorb  more  than  300 
calories  daily.  Therefore,  while  this  method  of  alimen- 
tation is  a  most  useful  adjunct,  and  is  of  great  help  in 
tiding  a  patient  over  an  emergency,  the  physician  should 
not  feel  that  he  is  in  any  sense  adequately  supplying  the 
needed  daily  calories. 

The  successful  administration  of  nutrient  enemas  depends 
on  knowledge  and  care.  With  careless  or  faulty  technic, 
the  food  is  not  retained,  the  rectum  and  anus  become  ir- 


346  GENERAL   CONSIDERATIONS    OF   DIET 

ritated,  and  failure  is  the  result.  In  hospitals,  or  where  a 
specially  trained  nurse  is  at  hand,  the  physician  may  give 
general  directions,  but  in  the  absence  of  these,  very  ex- 
plicit directions  are  requisite. 

Method. — The  rectum  should  be  cleansed  well  by  a  rather 
high  enema  of  normal  salt  solution  at  least  once  daily. 
Cleansing  before  each  feeding,  as  some  recommend,  is 
too  often.  Should  the  rectum  be  inflamed,  a  solution  of 
boric  acid  may  be  used  instead  of  the  salt  solution,  and  if 
there  is  much  stringy  mucus,  a  solution  of  sodium  bicar- 
bonate— a  teaspoonful  to  the  pint  of  water — is  helpful. 
If  there  is  an  inclination  toward  tenesmus,  a  return  flow 
catheter  or  recurrent  tube  should  be  used  for  the  cleansing 
enema.  The  temperature  of  the  cleansing  enema  may  be 
as  hot  as  95°  F.  to  105°  F.,  but  the  nutrient  enema  should 
be  strictly  between  90°  and  95°  F.,  as  solutions  too  hot  or 
cold  are  promptly  rejected. 

Unless  prevented  by  some  condition  of  the  disease,  the 
patient  should  lie  on  his  left  side  with  his  hips  well  elevated. 
A  rectal  tube  or  large  catheter  may  be  employed,  not  too 
large,  though;  a  tube  about  16  or  18  English  is  proper, 
smaller  ones  being  needed  for  children.  The  tube  should 
be  well  lubricated,  but  not  with  glycerin. 

As  the  tube  is  introduced,  it  should  be  rotated  slightly, 
and  if  any  folds  of  the  rectum  impede  its  progress,  a  little 
fluid  should  be  allowed  to  flow.  This  will  "balloon"  the 
rectum,  and  allow  the  tube  to  advance  easily  8  or  10 
inches,  or  even  more.  It  is  well  for  the  tube  to  ascend 
as  high  in  the  rectum  as  is  practicable,  but  if  efforts  are 
put  forth  to  carry  it  too  high,  the  tube  is  liable  to  double 
upon  itself  in  the  distended  rectum,  and  the  inflowing 
current,  instead  of  pointing  up,  will  point  down. 

The  enema  should  be  allowed  to  flow  in  slowly  from  a 
funnel  or  fountain.  The  former  Davidson  syringe,  in 
which  the  fluid  was  sent  in  by  intermittent  jets,  did  not 
give  satisfaction.  Air  should  not  be  injected  with  the  fluid. 
Should  the  patient  complain  of  a  desire  to  evacuate  the 


RECTAL   ALIMENTATION  347 

bowel,  the  flow  should  be  discontinued  until  the  desire 
abates,  and  then  slowly  resumed.  By  tact  and  patience 
the  enema  may  be  injected  with  perfect  comfort  gen- 
erally, but  if  the  nurse  is  hurried  or  the  patient  fretted, 
the  fluid  will  in  all  probability  be  ejected  in  a  short 
while. 

After  the  injection  the  patient  should  lie  as  quietly  as 
possible  for  an  hour  or  more,  and  be  instructed  to  use 
every  effort  to  retain  the  enema.  A  pad  or  towel  may  be 
pressed  over  the  anus  for  about  tw^enty  minutes,  and  in  the 
meanwhile,  if  the  nurse  will  divert  the  patient's  mind  from 
his  rectum,  the  uncomfortable  sensations  of  fulness  there 
will  soon  cease.  If  the  rectum  is  very  irritable,  the 
nutrient  enema  may  be  preceded  by  a  small  suppository  of 
opium  and  belledonna,  or  a  very  small  rectal  injection  of 
warm  starch  water  containing  about  fifteen  drops  of  the 
tincture  of  opium.  The  frequent  use  of  opium,  however, 
is  to  be  deprecated.  Should  hemorrhoids  complicate  the 
situation,  they  may  be  painted  with  a  2  per  cent,  cocain 
solution  previous  to  introducing  the  tube,  and  a  soothing 
ointment  may  be  applied  between  times. 

The  amount  to  be  given  at  each  injection  is  important, 
and  should  be  regulated  with  judgment.  As  a  rule  it  is 
not  well  to  exceed  8  oiinces,  and  6  are  generally  better. 
Should  this  be  retained  with  difficulty,  a  smaller  amount 
should  be  used. 

The  interval  of  time  between  enemas,  and  the  number 
daily  will  depend  on  the  condition  of  the  rectum.  For  a 
few  times  it  is  feasible  to  administer  nutrient  enemata 
four  hours  apart,  but  it  is  seldom  that  a  rectum  will  bear 
them  long  unless  about  six  hours  are  allowed  to  elapse 
between.  About  four  times  daily  will  be  generally  found 
the  limit,  if  this  method  of  feeding  has  to  be  kept  up  for  an 
extended  period. 

Indications  for  Nutrient  Enemata. — (i)  In  extremely 
weakened  conditions,  as  in  fevers  or  other  exhausting 
diseases. 


348  GENERAL   CONSIDERATIONS    OF   DIET 

(2)  In  obstruction  of  the  pharynx  or  esophagus,  where  the 
patient  is  unable  to  swallow  food. 

(3)  In  organic  diseases  of  the  stomach  (malignant  or  non- 
malignant),  where  it  is  desired  to  give  that  organ  a  com- 
plete rest.  Also,  though  rarely,  in  severe  vomiting  from 
irritable  stomach,  of  nervous  origin. 

(4)  In  delirious,  comatose,  or  insane  persons,  where 
it  is  impracticable  to  feed  through  the  mouth. 

RECIPES  FOR  NUTRIENT  ENEMATA 

Egg-and-milk  Enema. 

Eight  ounces  sweet  milk 170  calories 

Three  eggs 200  calories 

Half  teaspoonful  of  salt, 

370  calories 
Starch-and-milk  Enema. 

About  two  ounces  starch 250  calories 

Eight  ounces  sweet  milk 170  calories 

420  calories 
Sugar-and-milk  Enema. 

Two  ounces  grape  sugar 246  calories 

Eight  ounces  sweet  milk 170  calories 

416  calories 
Von  Leube's  Milk -peptone  Enema. 

Eight  ounces  sweet  milk 170  calories 

Two  ounces  peptone 100  calories 

270  calories 
Singer's  Nutrient  Enema. 

Four  ounces  sweet  milk. 

Four  ounces  wine. 

Yolks  of  two  eggs. 

Half  teaspoonful  salt. 

One  teaspoonful  Witte's  peptone. 

In  addition,  the  enemata  may  be  thickened  with  a  little 
mucilage,  or  a  few  drops  of  tincture  of  opium  may  be  added. 
Should  the  rectum  be  extremely  sensitive,  the  enema  may 
consist  of  plain  warm  water,  to  which  is  added  the  albumens 
of  two  or  three  eggs.     It  is  the  custom  to  add  to  these 


OTHER   METHODS    OF   NOURISHING   THE  BODY  349 

enemata  various  predigested  foods,  alcoholic  or  otherwise, 
and  they  seem  to  be  borne  quite  well,  though  their  sup- 
portive value  is  problematical. 

OTHER  METHODS  OF  NOURISHING  THE  BODY 

Food  suppositories  have  been  suggested,  but  have  not 
proved  of  any  real  benefit. 

Nutrient  inunctions  with  oils  or  cocoa  butter  have  been 
used  in  conditions  of  great  emaciation  with  some  apparent 
benefit.  The  pediatrists  esteem  these  inunctions  highly, 
and,  whether  or  not  the  oily  substance  is  absorbed  to  any 
great  extent,  it  aids  in  keeping  the  skin  soft  and  pliable. 

Intravascular  feeding  has  been  suggested  by  some  for 
states  of  sudden  and  extreme  exhaustion,  as  in  Asiatic 
cholera  or  cholera  nostras.  The  injections  have  con- 
sisted of  milk,  or  milk  and  peptone  solutions.  This  method 
is  not  to  be  recommended,  and  the  employment  of  normal 
saline  solution,  when  it  is  urgently  necessary  to  get  fluid 
into  the  body,  is  preferable  in  every  respect. 

Saline  Infusions. — These  are  given  subcutaneously,  and 
are  indicated  in  conditions  where  rectal  saline  irrigations 
cannot  be  utilized,  as  in  certain  intestinal  diseases  where  a 
quick  affect  is  desired,  as  collapse  from  hemorrhage  or 
shock.  Saline  infusions  are  also  of  use  when  large  quantities 
of  fluids  have  been  lost  by  the  body,  as  in  excessive  diar- 
rheas of  cholera  or  dysentery.  They  are  sometimes  em- 
ployed in  uremic  coma,  or  in  suppression  of  urine. 

The  most  eligible  location  for  administering  the  infusion 
is  between  the  chest  wall  and  the  mammary  gland,  or 
less  preferably,  deep  in  some  muscle,  as  in  the  lumbar  region, 
abdominal  wall,  or  buttocks.  The  injection  should  be 
given  under  careful  aseptic  precautions.  No  special 
apparatus  is  required  beyond  a  fountain  syringe,  to  which 
is  attached  an  aspirating  needle.  The  various  complicated 
devices  for  saline  infusions  are  prone  to  get  out  of  order, 
and  are  more  liable  to  carry  infection. 


35°  GENERAL   CONSIDERATIONS   OP   DIET 

The  infusion  should  be  warm,  and  should  be  allowed 
to  run  in  slowly  and  without  force.  Sometimes  as  much 
as  I  or  2  quarts  can  be  injected  into  one  place.  The  mix- 
ture should  be  the  normal  salt  solution,  0.6  per  cent. 

The  physician  who  carefully  and  zealously  protects  at 
all  times  the  upkeep  of  the  body,  who,  if  he  errs,  does  so 
on  the  side  of  a  liberal  regimen,  who  realizes  that  primarily 
the  bodily  furnace  must  be  systematically  "stoked" 
lest  the  units  of  heat  and  energy  fail  to  be  provided,  will 
hold  a  much  superior  tactical  position  over  the  one,  who, 
though  skilled  in  all  other  therapeutic  procedures,  loses 
sight  of  a  rational  and  sustaining  diet. 


CHAPTER  XIV 
DRUG  THERAPY  IN  DIGESTIVE  DISEASES 

There  are  many  diseased  or  disturbed  conditions  of 
digestion  in  which,  by  proper  and  logical  drug  medication, 
the  symptoms  are  alleviated  or  the  abnormal  condition 
relieved.  Drugs  can  never  take  the  place  of  hygiene  nor 
diet,  but  they  hold  certain  logical  indications  in  disease, 
and,  when  properly  administered,  afford  tangible  and 
potential  benefit. 

Alkalies. — There  is  some  divergence  in  views  as  to  the 
effects  of  alkalies  upon  digestion.  According  to  Jaworski, 
small  doses  of  bicarbonate  of  soda  or  other  such  alkalies 
(15  or  20  grains)  would  first  decrease  gastric  acidity  for  a 
short  while,  and  then  increase  it.  On  the  other  hand,  if 
sufficiently  large  doses  of  these  alkalies  (two  or  three 
teaspoonfuls)  are  given  for  a  sufficiently  long  time,  the 
decreasing  effect  would  persist  without  interfering  with 
the  motor  power  of  the  stomach.  Furthermore,  it  seems 
that  when  the  alkali  reaches  the  duodenum,  the  secretion 
of  bile  increases,  and  when  quite  large  doses  are  given,  the 
intestinal  contents  are  liquefied,  and  peristalsis  somewhat 
increased. 

When  small  or  large  doses  of  alkalies  are  given  im- 
mediately or  a  short  time  before  meals,  they  seem  to 
stimulate  the  compensatory  powers  of  the  oxyntic  cells 
of  the  stomach,  and  increased  acidity  results.  Waters 
containing  alkaline  salts,  when  taken  warm  and  one  hour 
before  meals  for  several  weeks,  tend  to  decrease  acidity, 
and  exert  the  effect  of  stomach  lavage. 

Bicarbonate  of  soda,  while  a  dependable  and  non-irritat- 
ing alkali,  gives  off  carbon  dioxid  in  the  stomach,  causing 
distention,   and  in  some  sensitive  patients,  real  distress. 

351 


352  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

Calcined  magnesia  will  neutralize  acidity  in  rather  smaller 
doses  than  the  soda,  causes  but  little  if  any  distention,  and 
gives  a  slight  laxative  effect. 

Where  the  bowels  are  inclined  to  diarrhea,  the  heavy 
calcined  magnesia,  or  magnesia  ponderosa,  will  control 
the  acid  without  upsetting  the  bowels.  It  might  be 
mentioned  that  calcined  magnesia,  in  large  doses  and  taken 
for  a  long  time,  has  been  reported  to  accumulate  in  the 
intestines,  forming  concretions.  This,  I  consider  quite 
improbable,  as  an  experience  of  many  years  with  the  admin- 
istration of  this  alkali  has  caused  no  such  trouble  in  cases 
under  my  observation.  Carbonate  of  magnesia,  and 
carbonate  of  calcium  are  also  employed  as  antacids,  but 
are  less  efficient.  Bismuth  in  its  different  salts  is  an  eligible 
antacid,  possessing  besides  both  an  antidiarrheal  effect 
and  a  sedative  effect  by  its  mechanical  properties,  which 
will  later  be  discussed. 

In  prescribing  alkalies,  they  may  be  given  in  powder, 
in  solutions  with  water,  or  in  suspension  in  some  liquid. 
Both  magnesia  and  bismuth  can  be  obtained  as  milk  of 
magnesia  or  bismuth,  and  in  this  form  are  sometimes  more 
easily  given  than  in  the  dry  powder.  It  has  also  been  dem- 
onstrated that  when  several  non-irritating  alkalies  are  com- 
bined, the  antacid  effect  desired  is  obtained  by  somewhat 
smaller  doses.  Cathartics,  antifermentatives,  carminatives, 
astringents,  sedatives,  or  other  medicaments  may  be 
combined  with  alkalies  in  various  ways,  as  dictated  by  the 
judgment  of  the  physician. 

Suggestive  combinations  of  alkalies,  etc. : 

I^.     Magnesias  ustse, 

Sodse  bicarb aa   5vi 

Ext.  belladonnse gr.  i 

SiG. — One  teaspoonful  either  dry  on  the  tongue  and  fol- 
lowed by  water,  or  stirred  up  in  half  glass  water, 

I^.     Magnesias  ustas, 
Sodae  bicarb., 
Bismuth,  subnit .  aa   5vi. 

SiG.— ^One  teaspoonful  one  to  two  hours  after  meals. 


ALKALIES  353 

I^.     Magnesias  ustas, 

Sodfe  bicarb aa   5  vi. 

Pv.  rhei, 

Sacch.  lactis aa   5ii- 

SiG. — ^One  teaspoonful  one  or  two  hours  after  meals. 

This  prescription  is  useful  where  there  is  hyperacidity 
with  constipation,  but  the  dose  must  be  reduced,  if  the 
bowels  become  too  loose. 

I^.     Magnesise  ustas, 

vSodse  bicarb aa   3vi. 

Pv.  carbo.  ligni 5i- 

Cretae  preparatas oiv. 

SiG. — One  teaspoonful  one  or  two  hours  after  meals. 

This  prescription  is  indicated  in  acidity  combined  with 
a  frothy  diarrhea  with  much  gas. 

I^.     Cerii  oxalatis, 

Bismuth,  subcarbonatis aa   3ii- 

Bismuth,  subgallatis, 

Cretffi  preparatse aa   oiv. 

Carbonis  lig oi- 

SiG. — One  teaspoonful  stirred  in  half  glass  of  water  a  half 

to  one  hour  after  meals,  and  repeated  if  necessary. 

This  prescription  will  be  found  helpful  in  the  pain  due 
to  hyperchlorhydria,  and  may  be  repeated  several  times  at 
half-hour  intervals  till  the  acidity  is  corrected. 

The  ingredients  in  the  above  prescriptions  may  be  varied 
in  quantity,  especially  the  rhubarb  or  the  belladonna. 
Where  the  patient  desires  a  change,  but  the  physician 
considers  no  change  is  needed,  the  addition  of  one  or  two 
grains  of  carmine,  or  a  few  drops  of  oil  of  anise  or  fennel 
will  decidedly  change  the  appearance  or  taste,  while  the 
therapeutic  effects  remain  the  same.  These  changes 
exert  a  certain  psychotherapeutic  effect,  and  should  not  be 
disregarded.  It  is  not  well  to  give  a  patient  one  formula 
too  long.  The  digestive  organs  tend  to  become  habituated 
to  it,  while  the  patient  may  feel  that  perhaps  the  physician 
is  not  following  up  the  case  with  sufficient  care  and  interest. 

When  alkalines  are  to  be  administered  in  liquid  form,  the 
milk  of  magnesia  or  milk  of  bismuth  is  the  most  satis- 
23 


354  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

factory.  Lime  water  may  be  added  to  milk,  but  taken 
alone,  does  not  taste  well  nor  seem  to  exert  a  pleasant 
antacid  effect.  To  these  milky  preparations  may  be 
added  a  variety  of  flavoring  agents,  carminatives,  or 
laxatives,  in  proportions  to  suit  each  individual  case. 

Tonic,  stomachics,  or  stimulants  should  not  enter  into 
the  composition  of  antacid  prescriptions,  for  they  are 
antagonistic  in  their  very  nature. 

The  following  are  good  antacid  prescriptions  in  liquid 
form: 

I^.     Spts.  lavandulse  co 3i- 

Lactis  magnesias q.s.  ad  giv. 

SiG. — Two  teaspoonfuls  a  half  to  one  hour  after  meals. 

I^.    Tr.  cardamomi  co 3ii- 

Lactis  magnesiae q.s.  ad.  giv. 

SiG. — Two  teaspoonfuls  after  meals. 

When  the  bowels  are  too  loose,  or  the  above  exert  a  too 
laxative  effect,  the  following  may  be  substituted. 

I^.     Spts.  lavandulffi  co 5i. 

Lactis  bismuthi q.s.  ad.    giv. 

SiG. — Two  teaspoonfuls  after  meals. 

Where  there  is  much  flatulence,  the  addition  of  a  small 
amount  of  resorcin  and  spirits  of  anise  or  fennel  will  be 
most  helpful. 

I^.     Spts.  anisi 3ii- 

Resorcinolis gr.  xv. 

Lactis  magnesiee q.s.  ad.    giv. 

SiG. — One  or  two  teaspoonfuls  after  meals,  and  repeat  at 

half-hour  intervals,  as  needed  for  flatulence. 
I^.     Spts.  foenculi 3ii- 

Resorcinolis gr.  xv. 

Lactis  magnesiae q.s.  ad.    §iv. 

SiG. — One  or  two  teaspoonfuls  as  needed  for  flatulence. 

Where,  in  stagnation,  there  is  great  fermentation  and 
much  excess  of  organic  acids,  this  may  be  used: 

I^.     Creosoti  (beechwood) gr.  vii. 

Sodii  bicarb 3  ii- 

Pv.  acaciae. 5i- 

Spts.  lavandulas  co Si- 
Aquae q.s.  ad.  3iii-' 

SiG. — One  teaspoonful  after  meals. 


ALKALINE    WATERS  355 

In  the  presence  of  nausea  combined  with  the  flatulence 
and  heartburn,  of  which  some  patients  complain  so  bit- 
terly, use  this: 

I^.     Spts.  amygdalas  amare 5ii- 

Resorcinolis " gr.  xx. 

Lactis  magnesias q.s.  ad.    ^iv. 

SiG. — One  teaspoonful  after  meals,  and  repeat  as  needed. 

Where  there  is  painful  flatulence,  Lockwood  suggests 
this: 

I^.     Orthoformi, 

Bismuthi  subcarbonatis aa   5ii- 

Mist,  cretas  co q.s.  ad.    ^iv. 

SiG. — One  teaspoonful  in  a  little  water  as  needed. 

For  a  simple  antacid,  which  may  be  given  somewhat  in 
the  nature  of  a  placebo,  to  perhaps  keep  the  patient  satisfied 
while  investigations  proceed,  this  will  answer : 

I^.     Mist,  rhei  et  sodii, 

Lactis  magnesiae aa   5ii- 

SiG. — One  or  two  teaspoonfuls  after  meals. 

As  a  stimulating  carminative,  a  small  amount  of  spirits 
of  ginger  may  be  included,  or  where  a  decided  carminative 
is  needed,  the  milk  of  asafetida,  either  alone,  or  in  equal 
parts  with  the  milk  of  magnesia  may  be  given  at  frequent 
intervals. 

Alkaline  Waters. — These  have  their  useful  place,  but 
through  seductive  advertising,  many  patients  take  them 
without  proper  advice,  and  with  more  injury  than  benefit. 

Should  atony,  gastroptosis,  or  pylorospasm  be  present, 
these  waters  should  be  allowed  in  minimum  doses,  if  at  all. 

The  best  alkaline  waters  are  Saratoga,  Vichy,  or  in 
Europe,  Pachingen,  Giesshubel,  or  Vichy.  I  have  noticed 
occasional  good  effects  from  these  waters,  when  taken  before 
breakfast,  and  as  a  temporary  means  of  relief,  but  they  pos- 
sess no  advantage  over  the  alkaline  powders  and  liquids 
ordinarily  prescribed  for  the  same  purpose. 

In  many  instances  a  sojourn  at  a  health  resort,  where 
alkaline  waters  are  freely  ingested,  proves  highly  beneficial, 


356  DRUG    THERAPY   IN   DIGESTIVE    DISEASES 

but  not  so  much  from  the  water,  as  from  the  rest,  the 
change  of  food  and  environment,  and  the  fihing  of  perhaps  a 
morbid  mentaHty  with  new  thoughts  and  sensations. 

Carlsbad  water  is  sometimes  of  service  in  hyperacidity 
due  to  ulcer,  gall-bladder  infections,  or  chronic  gastritis. 
In  such  conditions  a  glass  of  Sprudel,  as  hot  as  can  be 
swallowed,  may  be  slowly  drunk  on  arising.  Another 
glass  may  be  taken  before  supper,  but  not  enough  to  cause 
undue  looseness  of  the  bowels. 

The  artificial  Carlsbad  Sprudel  salt  may  be  obtained,  and 
in  teaspoonful  doses,  diluted  in  hot  water,  answers  the  pur- 
pose quite  well.  Sodium^  chlorid  waters,  such  as  Ha- 
thorne  and  Congress  water  in  this  country,  or  Kissingen 
and  Wiesbaden  in  Europe,  do  harm,  and  should  not  be 
prescribed. 

Acids. — When  there  is  a  deficiency  or  absence  of  hydro- 
chloric acid  in  the  gastric  secretions,  some  form  of  acid, 
preferably  hydrochloric,  is  indicated.  It  should  be  under- 
stood, however,  that  by  internal  administration  we  can 
not  equal  in  quantity  or  character  the  normal  secretion, 
and  the  most  we  can  do  is  to  aid  and  supplement  the 
depressed  or  waning  digestive  powers.  Again,  in  some 
individuals  whose  stomachs  secrete  absolutely  no  acid, 
the  gastric  mucosa  is  intolerant  of  hydrochloric  acid,  even 
in  diluted  form,  and  suffers  much  discomfort  or  pain  if  its 
use  is  persisted  in. 

Hydrochloric  acid  should  always  be  given  in  its  dilute 
form — never  chemically  pure — should  be  further  diluted 
with  sufficient  water,  and  if  continued  for  any  length  of 
time,  should  be  taken  through  a  tube  so  as  not  to  injure 
the  teeth. 

Hydrochloric  acid,  in  doses  of  ten  to  twenty  drops,  may 
be  mixed  with  a  half  or  two-thirds  glass  of  water,  and  sipped 
during  a  meal,  or  taken  soon  after.  It  may  be  combined 
with  pepsin,  though  the  glamour  once  connected  with 
pepsin  has  been  practically  dispelled.  Pepsin  serves  well 
as  a  vehicle  for  the  administration  of  acids  and  several  other 


ACIDS  357 

medicaments,  but  alone  has  little  or  no  effect  on   gastric 

digestion. 

The   following   are   suggestive   prescriptions   containing 

this  acid: 

^.     HCl.  dil oiv. 

Ess.  pepsini 5  iiiss. 

SiG. — -One  teaspoonful  in  water  half  hour  after  meals. 

I^.     HCl.  dil oiv. 

Elix.  enzymis 5  iiiss. 

SiG. — One  teaspoonful  in  water  half  hour  after  meals. 

I^,     HCl.  dil., 

Tr,  nucis  vom aa  5iv. 

SiG. — Ten  drops  in  water  half  hour  after  meals. 

I^.     HCl.  dil 3iv. 

Tr.  nucis  vom 3  ii- 

Tr.  gentianas  co q.s.  ad.  5iv. 

SiG. — One  teaspoonful  in  water  after  meals. 

The  last  prescription  may  be  varied  by  substituting  for 
the  gentian,  compound  tincture  of  cinchona,  or  some  of 
the  aromatic  elixirs,  as  elixir  of  calisaya. 

Occasionally,  after  the  hydrochloric  acid  has  been  given 
for  some  time,  it  is  advisable  to  vary  it  for  a  time  with 
dilute  phosphoric  acid.  This  acid,  however,  is  useful 
mainly  as  a  substitute,  and  should  not  displace  the  hy- 
drochloric acid  for  too  long  a  period. 

Oxyntin,  a  proprietary  acid  albumin,  is  sometimes  help- 
ful in  antacid  states.  A  teaspoonful  of  the  powder  may  be 
taken  either  in  wafer  paper  or  placed  in  sandwich  form 
between  two  small  slices  of  bread  and  butter,  and  taken 
at  meals.  Two  grains  of  oxyntin  are  about  equal  to  i 
minim  of  dilute  hydrochloric  acid. 

Another  preparation  now  on  the  market,  and  of  seeming 
value,  is  a  tablet  called  acidol.  These  tablets  come  in 
two  strengths,  one  representing  2  minims  of  the  dilute 
acid,  the  other  representing  8  minims.  They  may  be 
dissolved  in  water  and  taken  at  meals,  and  are  especially 
useful  in  senile  achylia. 

Other  somewhat  vaunted  preparations  are  gasterin  and 
hepatin,  which  are  obtained  from  the  gastric  juice  of  dogs 


358  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

through  gastric  fistulas.  These  preparations  are  active 
digestants,  but  are  expensive,  must  be  obtained  fresh, 
and  are  not  easily  kept  in  an  efficient  condition. 

Stomachics. — These  are  agents  intended  to  stimulate 
gastric  secretion,  and  with  it  to  sharpen  the  appetite. 
Stomachics  are  seldom  indicated  in  hypersecretion,  but 
in  sluggish  secretion,  deficient  acidity,  or  achylia  gastrica. 
They  should  be  given  before  meals,  and  preferably  on  an 
empty  stomach. 

The  dilute  acids  in  i  to  2  minim  doses,  well  diluted  with 
water,  exert  a  moderate  stomachic  effect,  but  the  bitter 
tonics  are  more  efficient,  and  to  them  may  the  acid  be 
added. 

Among  the  most  representative  of  this  class,  are  con- 
durango,  quassia,  cinchona,  nux  vomica,  gentian,  hydrastis, 
and  calisaya. 

The  following  are  useful  stomachic  prescriptions: 

I^.     Tr.  condurango 5iii- 

Tr.  nucis  vom 5ii- 

Tr.  Gentianae  co q.s.  ad.  §iv. 

SiG. — One  teaspoonful  in  water  half  an  hour  before  meals. 

I^.     HCl.  dil 3i. 

Tr.  condurango 5  iii- 

Tr.  gentianas  co §  iiiss. 

SiG. — One  teaspoonful  in  water  before  meals. 

I^.     Tr.  nucis  vom 3ii- 

Tr.  quassiae 5  iii- 

Tr.  cinch onae  co 5ii- 

Aquas q.s.  ad.  Siv. 

SiG. — One  teaspoonful  in  water  before  meals. 

I^.     Spts.  Lavandulse  co., 

Tr.  condurango aa  3iv. 

SiG. — Twelve  drops  in  water  before  meals. 

I^.     Hydrastinse gr.  i. 

Sacch.  lactis 3i. 

Fiat  capsute 20. 

SiG. — One  capsule  half  hour  before  meals. 

Orexin  is  a  useful  stomachic,  not  being  as  well  known  as 
it  should.  This  drug  is  in  powder  form,  and  may  be 
prescribed  in  3 -grain  capsules,  about  two  hours  before  meals. 


ARTIFICIAL   FERMENTS  359 

It  is  indicated  in  anorexia  with  low  or  absent  hydrochloric 
acid  secretion,  and  is  contraindicated  in  hyperacidity  or 
any  inflammatory  states  of  the  gastric  mucosa. 

Artificial  Ferments. — Ptyalin,  the  starch-splitting  fer- 
ment of  the  salivary  glands,  acts  in  alkaline  media,  be- 
coming inert  in  the  presence  of  an  acid  reaction.  This 
ferment  in  an  artificial  form  has  been  recommended  in 
doses  of  7  to  15  grains,  combined  with  an  alkali,  in  disease 
of  the  sahvary  glands  and  deficient  starch  digestion.  This 
does  not  seem  to  give  practical  results,  and  the  abnormal 
conditions  in  which  it  has  been  used  can  be  better  controlled 
by  other  means. 

Diastase,  or  Taka-Diastase  (the  latter  being  perfected 
by  Takamine)  are  isolated  ferments  in  powder  form  in- 
tended for  the  artificial  digestion  of  amylaceous  foods,  and 
holding  the  same  relation  thereto  that  pepsin  does  to  the 
proteins.  Taka-Diastase  can  be  obtained  in  a  liquid  form, 
however,  though  this  is  hardly  as  efficient  as  the  powder. 
This  powder,  in  2-  to  5 -grain  doses,  may  be  given  soon  after 
meals,  and  is  useful  in  amylaceous  dyspepsia. 

Pepsin  is  seldom  indicated  alone,  though  it  seems  to 
exert  a  useful  influence  when  given  with  hydrochloric  acid. 
Though  it  holds  a  strong  place  in  the  minds  of  the  laity  as  a 
digestant,  it  really  possesses  but  little  efficacy  when  given 
alone. 

Papain,  a  ferment  from  the  juice  of  the  papaw  fruit, 
exerts  a  disintegrating  rather  than  a  completely  digestive 
action  upon  the  proteins  and  starches.  Its  action  upon  the 
proteins  takes  place  in  alkaline  and  neutral  media,  as  well 
as  slightly  acid  ones.  In  doses  of  2  to  5  grains  it  has  been 
employed  in  conditions  of  subacidity  where  hydrochloric 
acid  was  not  well  tolerated,  but  with  rather  problematical 
results. 

Pancreatin,  an  extractive  from  the  pancreas,  transforms 
starch  into  sugar,  emulsifies  fats,  and  peptonizes  albumin- 
oids. It  acts  in  alkaline  or  neutral  media  only,  and  should 
be  administered  in  capsules,  which  do  not  dissolve  in  the 


360  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

stomach.  The  dose  is  i  to  5  grains.  A  preparation, 
pancreon,  is  a  combination  of  pancreatin  with  galhc  acid, 
the  latter  protecting  the  former  from  being  destroyed  in  the 
stomach.  This  ferment  is  given  to  aid  intestinal  digestion, 
should  be  combined  with  alkalies,  and  administered  at 
least  two  hours  after  meals. 

Cathartics. — This  term  is  modified  in  degree  as  to  the 
amount  of  intestinal  peristalsis  produced,  a  mild  amount 
being  termed  laxative,  a  greater  amount  cathartic,  while 
one  producing  a  severe  and  perhaps  exhausting  peristalsis,  is 
termed  a  drastic  cathartic.  The  degree  of  intestinal 
peristalsis  produced  by  an  agent  or  drug  defines  it,  and, 
therefore,  no  drug  may  be  termed  any  one  of  these  unless 
the  dose  is  taken  into  account. 

The  cathartic  effect  may  be  produced  by  direct  stim- 
ulation of  the  nerves  of  the  intestines,  by  irritation  of 
the  intestinal  mucosa,  by  osmosis,  by  liquefying  the  in- 
testinal contents,  or  by  stimulating  the  central  nervous 
system. 

Eserin    exerts    its    laxative    effect    by    stimulating    the 
central  nervous  system,  and  has  been  used  subcutaneously. 
Its  action  is  somewhat  uncertain.     The  dose  is  from  i/ioo. 
to  1/50  grain. 

Hormonal,  a  peristaltic  hormon  isolated  from  the  spleen, 
is  reported  as  having  exerted  strong  and  effective  peris- 
talsis in  several  cases  of  post-operative  intestinal  paralysis. 
It  should  be  injected  into  the  muscle  in  doses  of  5  to 
20  c.c.  This  should  be  followed  with  castor  oil  a  few 
hours  later. 

The  cathartic  agents,  medicinal  and  otherwise,  are  legion, 
and  only  those  will  be  mentioned  which  are  specially  useful 
in  digestive  disorders. 

Among  the  mildest  laxatives  are  compound  licorice 
powder,  one  or  two  teaspoonsful  being  given  at  bed-time, 
powdered  rhubarb,  5  to  20  grains  at  bed-time,  and  aromatic 
fluid  extract  of  cascara,  of  which  one  teaspoonful  may  be 
given.     These  preparations,  in  the  doses  mentioned,  usually 


CATHARTICS  36 1 

move  the  bowels  in  eight  or  ten  hours,  without  pain  or  dis- 
comfort. Much  like  these  is  the  fluid  extract  of  senna, 
though  slightly  stronger. 

Phenolphthalein  is  a  most  eligible  cathartic,  acting  much 
in  the  same  manner  as  the  salines,  but  seldom  causes  grip- 
ing, tenesmus,  or  other  disturbance.  The  dose  varies  from 
I  to  5  grains,  and  it  is  frequently  combined  w4th  other 
cathartic  drugs  with  advantage.  The  good  and  reliable 
effects  of  this  drug  have  been  utilized  by  the  manufacturers, 
and  many  preparations  with  phenolphthalein  as  their  active 
principle,  are  available.  Some  of  these  are  attractive  in 
appearance  and  pleasant  to  take,  but  possess  little  ad- 
vantage over  capsules  or  tablets  containing  the  plain 
powder. 

Calomel  has  been  highly  esteemed  for  many  years,  but 
lately  it  has  been  the  subject  of  iconoclastic  attacks,  and 
at  present  its  only  secure  place  in  gastrointestinal  condi- 
tions is  to  thoroughly  evacuate  .  the  bowels.  It  can  be 
combined  to  advantage  with  phenolphthalein,  podophyllin, 
rhubarb,  and  others,  and  is  best  given  in  divided  doses  about 
an  hour  apart. 

The  bitter  fluid  extract  of  cascara  is  more  energetic, 
and  in  doses  of  ten  to  thirty  drops  may  be  depended  on  to 
evacuate  the  bowels,  unless  there  is  some  mechanical 
obstruction. 

If  a  somewhat  decided,  even  drastic  effect  is  desired, 
there  may  be  given  powdered  extract  of  colocynth,  1/2 
grain,  aloin,  1/2  to  2  grains,  resin  of  podophyllin,  1/4 
to  I  grain,  or  resin  of  jalap,  1/4  to  i  grain.  As  these 
drugs  are  likely  to  cause  much  griping  and  pain,  it  is  well 
to  combine  with, them  as  a  corrective  a  little  extract  of  bel- 
ladonna or  Dover's  powder. 

Castor  oil  is  a  reliable  and  efficient  evacuant,  probably 
being  more  used  by  the  laity  than  any  other.  It  acts  both 
by  intestinal  irritation  and  lubrication,  and  in  doses  of 
two  teaspoonfuls  up  to  2  ounces,  or  even  more,  will  gen- 
erally  empty   the   bowels,    unless   there   is   some    decided 


362  DRUG    THERAPY   IN   DIGESTIVE   DISEASES 

obstruction.  When  a  very  large  dose  is  given,  the  excess 
is  carried  off  with  the  feces  practically  unchanged.  Because 
of  its  nauseous  taste,  many  object  to  it  very  strenuously, 
but  this  may  be  disguised  fairly  well  with  a  little  whiskey, 
wine,  or  extract  of  sarsaparilla. 

Liquid  albolene,  an  oily  hydrocarbon,  holds  a  useful 
place  as  a  mild  laxative.  It  may  be  given  alone  or  com- 
bined with  aromatics  in  doses  of  2  to  6  drams,  or  even 
more,  and  when  taken  regularly  in  small  doses  for  several 
days,  gives  good  results  in  spastic  constipation  or  constipa- 
tion from  strictures  in  the  intestines.  A  very  good  way 
to  administer  liquid  albolene  is  in  two-teaspoonful  doses, 
three  times  daily,  half-hour  after  meals,  until  movements 
of  the  bowels  set  up,  when  the  dose  may  be  gradually 
reduced.  Occasionally,  in  obstinate  constipation,  a  larger 
dose  may  be  required,  and  may  be  given  without  fear  of 
untoward  consequences. 

Liquid  paraffin,  another  similar  oily  hydrocarbon,  is 
an  efficient  evacuant,  and  may  be  taken  in  as  large  doses 
as  necessary.  It  may  be  given  either  in  small  doses  before 
meals,  or  in  a  half -ounce  up  to  4-  or  even  8 -ounce  doses  at 
bedtime. 

I  recently  saw  a  patient  of  Dr.  Bassler,  who  was  suffering 
from  multiple  strictures  of  the  small  intestine,  and  nothing 
would  produce  for  him  an  evacuation  of  the  bowels  except 
8  ounces  of  liquid  paraffin  taken  at  bedtime. 

Croton  oil,  in  one-drop  doses,  may  be  given  in  an 
emergency,  but  is  too  severe  and  drastic  for  ordinary  use. 

Agar-agar,  first  introduced  by  Adolf  Schmidt,  acts  by 
virtue  of  its  power  to  absorb  water,  and  also  as  a  mechanical 
stimulant.  In  the  form  of  "Regulin"  it  may  be  easily 
obtained,  and  given  either  alone,  or  preferably  with  such 
foods  as  cereals,  as  it  is  tasteless.  Its  administration 
should  be  preceded  by  a  single  dose  of  castor  oil  or  compound 
licorice  powder,  after  which  a  full  teaspoonful  may  be 
given  three  times  daily  until  regular  evacuations  set  in,  and 
then  gradually  reduced. 


CATHARTICS  363 

Following  are  a  few  eligible  cathartic  prescriptions: 

I^.     Pv.  aloes gr.  xx. 

Ext.  belladonnae, 

Ext.  nucis  vom aa  gr.  iii. 

Ft.  pil.  No.  XX, 
SiG. — One  or  two  pills  at  night. 
I^.     Aloini gr.  i 

Strych.  sulphatis K^-  go 

Est.  belladonnas gr.  I 

Pv.  ipecac S^-  ^s 

Ft.  pil.  I, 
SiG. — At  bedtime. 
I^.    F.  E.  Cascarse  arom. 

F.  E.  Sennse aa   5  i- 

SiG. — One  or  two  teaspoontuls  at  bedtime. 

I^.     F.  E.  Cascarae 5i- 

F.  E.  podophyllin 3ii- 

F.  E.  sennae 3vi. 

SiG. — One  teaspoonful  at  bedtime.      (Quite  energetic.) 

The  various  salines  and  saline  waters  have  their  uses, 
generally  as  hydragogue  cathartics,  and  are  best  adminis- 
tered on  an  empty  stomach.  The  Epsom,  Rochelle  and 
Glauber's  salts  are  well  known,  and  most  of  the  highly 
vaunted  laxative  salines,  either  in  solid  or  liquid  from,  now 
on  the  market,  owe  their  virtue  to  the  presence  of  these 
three. 

The  granular  effervescent  preparation  of  phosphate  of 
soda  is  most  useful,  combining  both  hydragogue  and  chola- 
gogue  properties.  It  is  indicated  in  autotoxic  conditions 
and  catarrhal  inflammation  of  the  gall-bladder  or  duct. 

Where  it  is  desired  to  give  a  saline  for  some  time,  the 
following  will  be  found  efficient,  causing  neither  griping 
nor  distress  and  producing  copious  watery  evacuations: 

I^.     Magnesiae  sulphatis, 

Potassii  bitart.  (C.  P.) aa   §ii. 

SiG. — Two  to  four  teaspoonfuls  in  half  glass  water  on 

arising.     (This  will  need  to  be  reduced  in  a  few  days.) 

Carminatives. — Very  many  patients  suffering  from  diges- 
tive disorders  complain  of  distressing  flatulence  after 
meals  or  at  other  times,  and  the  physician  is  called  upon  to 
give  remedies  for  this. 


364  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

Some  flatulence  is  caused  by  fermentation,  but  much  of  it 
is  due  to  swallowed  atmospheric  air,  as  previously  stated 
in  this  book. 

Carminatives  may  be  given  in  the  form  of  an  infusion,  as 
is  the  frequent  custom  in  Germany,  or  added  to  various 
alkalies,  and  should  be  prescribed  so  they  can  be  frequently 
repeated,  for  flatulent  patients  are  generally  nervous,  and 
are  not  satisfied  unless  they  are  taking  something. 

In  flatulence  and  meteroism  the  following  combinations 
may  be  used  to  advantage : 

I^.     Magnesiffi  ustas 5i- 

Bism.  salicyl ,  .    3i- 

Pv.  mentholis gr.  v. 

SiG. — One  teaspoonful  after  meals,  and  repeat  if  needed. 
I^.     01.  fceniculi, 

01.  mentholis, 

Magnesise  ustag aa    3  i- 

Ext.  belladonnse gr.  i. 

Ft.  pil.  No.  100. 
SiG. — Two  or  three  pills  after  meals. 
I^. ,   Spts.  anisi 3  iv. 

Resorcinolis gr.  xv. 

Lac.  magnesiae q.s.  ad.    §iv. 

SiG. — One  teaspoonful  as  needed  for  gas. 

I^.     Spts.  foeniculi »    3iv. 

Resorcinolis gr.  xv. 

Lac.  magnesias q.s.  ad.    §iv. 

SiG. — One  teaspoonful  as  needed  for  gas. 

I^.     Spts.  zingerberi oiv. 

Lac.  magnesiae 3ii- 

Lac.  bismuthi §iss. 

SiG. — One  teaspoonfuras  needed  for  gas. 

I^.     Tr.  cardamomi  co 3iv. 

Resorcinolis gr.  xv. 

Lac.  magnesise q.s.  ad.    §iv. 

SiG. — One  teaspoonful  as  needed  for  gas. 

Intestinal  Antiseptics. — This  term  is  a  misnomer,  for  the 
intestinal  tract  cannot  be  rendered  aseptic  under  any 
circumstances.  Under  conditions,  however,  of  protein 
putrefaction  in  the  small  intestine,  or  excessive  protein 
putrefaction  in  the  large,  in  which  the  patient  feels  un- 
comfortable in  the    abdomen,    with    bad    breath,    coated 


EMETICS  365 

tongue,  and  general  malaise,  the  following  prescriptions  seem 
to  exert  a  decidedly  beneficial  effect. 

I^.     Ichthyolis, 

Taka-diastaste aa   3ii- 

Ext.  nucis  vom gr.  iv. 

Altheas  rad q.s. 

Fiat  capsule  No.  30,' 

SiG. — One  capsule  two  and  a  half  hours  after  meals. 

I^.     Fel  bovis  purif ' 5iii- 

Magnesiae  carbonatis ' Si- 
Resin  podophyllin gr.  ii. 

01.  anisi gtt.  iii. 

Fiat  capsulas  No.  30. 

SiG. — One  capsule  two  hours  after  meals. 

There  are  several  preparations  marketed  by  pharma- 
ceutical houses  containing  glycocholate  and  taurocholate 
of  sodium,  which  seem  to  afford  some  benefit  in  these  condi- 
tions. I  might  mention  holadin  and  bile  salts,  which  come 
in  3 -grain  capsules,  and  should  be  given  two  hours  after 
meals,  and  tablogestin  tablets,  of  which  three  tablets  should 
be  given  two  hours  after  meals.  The  last-named  prepara- 
tion is  specially  useful  in  jaundice,  or  any  catarrhal  state 
of  the  bile- ducts. 

Among  other  antiseptic  and  antifermentative  drugs,  may 
be  mentioned  salol,  guaiacol,  thiocol,  benzonaphthol,  bis- 
muth salicylate,  menthol,  and  magnesia  salicylate. 

Emetics. — Plain  tepid  water,  if  given  in  sufficient  quan- 
tity, generally  acts  as  an  efficient  emetic.  In  order  to  get 
its  good  effects,  however,  it  should  be  drunk  in  quantities 
of  not  less  than  three  or  more  glasses,  so  that  its  volume  may 
mechanically  stimulate  the  stomach,  enabling  that  viscus 
to  "  auto-lavage  "  itself.  In  one  instance  I  gave  a  patient 
fourteen  glasses  of  water  before  emesis  occurred.  To  this 
water  may  be  added,  if  desired,  a  small  amount  of  alum, 
mustard,  or  sulphate  of  zinc,  which  increases  its  nauseous 
effect. 

Ipecac  in  large  doses  is  emetic;  in  small  doses  expec- 
torant; in  minute  doses,  antiemetic  and  tonic.  Narcotics 
inhibit  its  emetic  action.     The  dose  of  the  powder  as  an 


366  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

emetic  is  15  to  30  grains,  and  it  may  be  repeated  every 
half -hour  till  results  are  attained.  The  syrup  and  wine  are 
eligible  preparations  specially  for  children,  in  whom  a 
quick  emetic  effect  is  wished.  Either  may  be  given  in 
doses  of  a  half  to  two  teaspoonfuls. 

Tartar  Emetic. — The  use  of  antimonial  preparations  as 
emetics  is  fortunately  obsolete.  Their  action  is  slow,  and  is 
attended  with  prolonged  nausea  and  depression,  so  that 
other  emetic  drugs  should  be  selected  in  their  stead. 

Apomorphin  Hydrochlorid. — This  drug  is  the  most 
prompt  and  reliable  emetic  that  we  possess;  moreover  it 
causes  comparatively  little  nausea,  and  is  quickly  effective 
when  administered  hypodermically.  It  is  useful  in  poison- 
ing, when  swallowing  is  impossible,  or  when  the  state  of  the 
stomach  is  such  as  to  prohibit  the  use  of  a  mechanical  or 
irritant  emetic.  In  acute  alcoholism  it  is  exceedingly 
effectual,  both  to  empty  the  stomach  and,  by  its  relaxing 
power,  to  hasten  the  coming  of  soberness.  It  is  never 
given  by  the  mouth.  The  hypodermic  dose  is  from  1/20 
to  I /lo  of  a  grain,  and  it  is  better  to  give  the  former  dose, 
and  repeat,  is  necessary,  than  to  give  the  latter,  unless  quick 
results  are  greatly  desired. 

Antiemetics. — Among  these  are  cerium  oxalate,  menthol, 
dilute  hydrocyanic  acid,  creosote,  tincture  or  wine  of  ipecac 
in  drop  doses,  and  morphin.  Few  antiemetics  are 
useful  when  given  empirically,  and  it  appears  that  per- 
sonal peculiarities  and  idiosyncrasies  govern  largely  their 
efficiency. 

Chloretone  in  3 -grain  doses,  menthol  in  i-grain  doses 
combined  with  some  alkali  or  10  to  20-grain  doses  of  cerium 
oxalate  may  be  administered  at  frequent  intervals  for  nausea 
and  vomiting.  The  hypodermic  injection  of  morphine  gen- 
erally relieves  vomiting  for  a  while,  but  generally  the  after- 
effects make  the  nausea  worse.  There  is  no  known  infall- 
ible prescription  for  nausea  and  vomiting,  and  each  case 
must  be  managed  on  its  merits. 

Sedatives. — These  may  be  local  in  their  effect  upon  the 


GASTRIC    SEDATIVES  367 

stomach  and  intestines;  or  general,  affecting  the  whole 
body.  Opium  and  its  derivatives  act  in  both  ways,  dimin- 
ishing gastric  secretion,  and  preventing  the  stomach  from 
emptying  itself  in  the  proper  time.  This  drug  may  be  used 
in  acute  conditions,  but  should  be  avoided,  if  possible,  in 
any  diseases  that  tend  toward  chronicity. 

One  of  the  best  and  safest  gastric  sedatives  is  belladonna 
and  its  alkaloid,  atropin.  The  former  is  best  given  in 
granules  containing  the  solid  extract,  in  doses  of  one- 
fiftieth  to  one-tenth,  and  on  an  empty  stomach.  The  atro- 
pin may  be  given  in  doses  of  1/200  of  a  grain  repeated 
every  four  hours  until  some  dryness  of  the  mouth  and 
fauces  is  noticed.  Both  of  these  are  valuable  as  local 
sedatives  in  hyperacid  conditions  of  the  stomach ;  while  the 
atropin  is  indicated  in  excessive  serous  discharges  from  the 
intestines.  The  sedative  effect  from  belladonna  may  also 
be  obtained  by  using  it  as  a  suppository. 

Cocain,  as  a  gastric  sedative,  is  inefficient  and  dangerous, 
and  should  be  condemned. 

Orthoform,  a  patented  product,  has  no  chemic  relation 
to  cocain,  which  it  resembles  only  in  its  action  on  the  sen- 
sory nerve  terminations.  It  is  a  white  tasteless  powder, 
efficient  as  a  local  sedative  or  anesthetic  only  when  it  comes 
in  contact  with  exposed  sensory  nerves.  Internally  it 
may  be  given  in  doses  of  8  to  1 5  grains  for  the  pain  of  gastric 
ulcer  or  cancer.  It  does  not  relieve  the  pain  of  simple  gas- 
tralgia,  and  hence  has  been  employed  as  a  test  for  gastric 
ulcer.  It  should  not  be  given  in  connection  with  silver 
nitrate  or  bismuth  subnitrate. 

Anesthesin. — This  is  a  white  powder,  soluble  in  ether, 
alcohol,  fatty  and  ethereal  oils,  but  insoluble  in  water.  The 
hydrochlorid  of  anesthesin  may  be  given  in  doses  of  5  to  8 
grains  in  conditions  of  gastric  hyperesthesia  and  pain  from 
ulcer.     Doses  of  30  grains  have  not  proved  toxic. 

Many  of  the  bromid  salts  are  not  suitable  as  gastric  seda- 
tives, as  most  of  them  are  intrinsically  irritating  to  the  gas- 
tric mucosa.     The  bromid  of  strontium  is  perhaps  an  excep- 


368  DRUG    THERAPY   IN   DIGESTIVE   DISEASES 

tion,  while  the  bromid  of  sodium  is  perhaps  the  least  irritat- 
■  ing  of  the  others.  These  two  salts  may  be  given  in  1 5 -grain 
doses,  best  combined  with  a  pleasant  syrup  or  some  aro- 
matic vehicle. 

Chloral  in  i -grain  doses  exerts  a  local  sedative  effect 
and  may  be  given  frequently  in  gastric  neuroses. 

The  following  prescription  is  a  most  useful  one,  and  is 
sometimes  employed  as  a  therapeutic  test  as  between  or- 
ganic and  nervous  affections  of  the  stomach : 

I^.     Chloral 5ss. 

Strontii  brom 5iiss. 

Spts  anisi gtt.  x. 

Aquae  chloroformi.  .  ; q.s.  ad.    5iv. 

SiG. — One  teaspoonful  in  water  four  -or  five  times  daily. 

Among  the  general  sedatives  are  the  hypnotics,  anodynes, 
and  narcotics. 

The  influence  of  hypnotics  on  the  digestive  tract  in 
undoubtedly  irritating,  and,  in  dealing  with  patients  who 
suffer  from  insomnia  in  connection  with  digestive  disorders, 
efforts  should  be  made  to  overcome  the  insomnia  by  other 
means,  if  possible.  Among  the  least  irritating  hypnotics 
may  be  mentioned  trional,  in  20-grain  doses,  veronal,  in 
6-  to  lo-grain  doses,  and  medinal  in  6-  to  lo-grain  doses. 
The  last-named  preparation  is  rapidly  absorbed  and 
excreted,  so  that  its  hypnotic  effect  is  prompt,  uniform  and 
reliable,  while  its  cumulative  toxic  effects  are  not  so  liable 
to  occur  as  with  veronal.  It  may  be  used  hypodermically 
or  intramuscularly  in  doses  of  6  or  8  grains,  and  is  said  to 
be  particularly  efficient  in  sea-sickness. 

Of  late,  adalin  has  been  recommended  as  a  mild  and 
unirritating  hypnotic.  The  dose  is  7  to  10  grains,  and  may 
be  employed  in  peculiarly  irritated  conditions  of  the  gastric 
mucosa. 

In  apparently  neuralgic  conditions  of  the  stomach  or 
intestines,  where  in  reality  the  adjacent  muscles  are  gener- 
ally affected,  some  of  the  milder  coal-tar  preparations  are 
useful,    if    cardiac    strength    permits.     Among    the    most 


ASTRINGENTS  369 

reliable  and  least  irritating,  are  acetphenetidin  fphenacetin) , 
and  acetyl  salicylic  acid  (aspirin).  These  may  be  given  in 
5 -grain  tablets  or  powders  every  two  or  three  hours  for 
neuralgic  sensations.  Any  lividity  or  faintness  should 
cause  a  discontinuance  of  their  employment. 

Astringents  and  Styptics. — Among  these  are  adrenalin, 
alum,  bismuth  subgallate,  catechu,  tannic  acid  and  its 
various  derivatives,  kino,  silver  nitrate,  calcium  phosphate, 
lactate,  and  salicylate,  gelatin,  and  horse  serum. 

As  an  astringent  to  be  used  in  gastric  lavage,  nitrate  of 
silver  is  most  useful,  in  strength  of  i :  looo  down  to  i :  10,000. 

For  internal  administration  the  bismuth  preparations  are 
eligible,  but  should  be  given  in  one-  to  two-teaspoonful 
doses  to  be  effective.  The  indications  for  the  bismuth  salts 
are  hyperacidity,  gastric  erosions,  and  diarrhea. 

The  tannates  which  are  used  interna:lly  are  tannigen, 
tannalbin,  tannopin,  tannoform,  tannigenaform,  and  pro- 
tan.  These  preparations  are  said  to  pass  through  the 
stomach  unchanged,  and  to  be  gradually  decomposed  in  the 
intestines,  thus  exerting  an  astringent  effect  upon  the  entire 
intestinal  canal.  The  doses  are  from  five  to  fifteen  grains, 
and  any  one  of  these  powders  may  be  given  in  all  condi- 
tions requiring  an  intestinal  astringent.  The  tannigen  is 
probably  the  best  of  the  series,  though,  should  it  fail  to 
give  results,  others  may. 

The  calcium  salts  are  highly  esteemed  by  some  as  astrin- 
gents, being  recommended  in  15  to  30  grain  doses.  I  must 
confess  that  I  have  been  disappointed  in  their  use,  and  do 
not  recommend  them,  believing  other  astringents  to  be  far 
superior. 

Gelatin  is  indicated  as  an  astringent  after  hematemesis, 
and  is  usually  given  in  a  10  per  cent,  solution,  cold,  in  di- 
vided doses  of  1/2  ounce,  every  three  hours.  Gelatin  may 
also  be  obtained  in  sterile  tubes — 10  c.c.  doses — and,  given 
intramuscularly,  serves  the  same  purpose. 

The  use  of  serum,  either  from  a  donor,  whose  blood  has 
been  tested  for  hemolysis,  or  rabbit  or  horse  serum,  has 
24 


370  DRUG   THERAPY   IN   DIGESTIVE   DISEASES 

been  recommended.  Unless,  however,  the  patient  is  so 
situated  that  every  advantage  of  experience  and  technic  is 
at  hand,  this  would  best  be  omitted. 

The  vegetable  astringents,  catechu,  kino,  and  krameria, 
are  employed  in  serous  diarrheas  with  benefit,  and  may  be 
used  as  the  fluid  extract  or  tincture  in  doses  of  ten  to  fifteen 
drops,  diluted  with  water. 

Opium  and  its  derivatives  inhibit  every  secretion  in  the 
body  except  the  perspiration,  and  may  be  classed  among  the 
astringents  for  this  reason.  The  tincture  or  the  powdered 
opium  may  be  employed  in  serous  diarrheas,  but  their  use, 
except  in  emergent  cases,  is  to  be  deprecated. 

Digestives.- — ^This  term  means  but  little,  for  hydrochloric 
acid  is  a  digestive  in  anacid  conditions,  while  an  alkali 
aids  digestion  in  hyperacidity.  The  term,  therefore,  should 
be  relegated  to  the  obsolete. 

Anthelmintics. — The  principal  drugs  of  this  group  are 
kamala,  male-fern,  pelletierine,  quassia,  santonin,  spigelia, 
and  thymol. 

Kamala  is  obtained  from  the  glands  and  hairs  from  the 
capsules  of  Mallotus  philippinensis,  a  small  tree  growing  in 
Arabia,  China,  etc.  It  is  anthelmintic  and  purgative, 
sometimes  causing  nausea  and  colic,  but  seldom  vomiting. 
It  is  used  as  a  teniafuge,  and  to  expel  the  round  and  thread 
worms.  One  or  two  drams  are  given  suspended  in  water, 
mucilage  or  syrup,  and  repeated  in  four  hours,  if  neces- 
sary. As  a  remedy  against  tapeworm,  it  is  perhaps  next 
to  the  male-fern  in  efficiency,  and  requires  no  preparatory 
treatment. 

Aspidium,  or  male-fern,  is  the  rhisome  of  Dryoteris  Filix- 
mas.  An  important  active  principle,  which  is  also  tenia- 
fuge in  character,  is  filmaron.  The  dose  of  the  male-fern  is 
from  1/2  to  I  dram  in  a  single  dose,  fasting,  and  followed  by 
a  brisk  purgative.  The  oleoresin  aspidii  is  the  form  gener- 
ally prescribed. 

Pomegranate  contains  an  active  mixture  of  alkaloids 
named  pelletierine,  which  is  soluble  in  water.     The  decoc- 


ANTHELMINTICS  3  7 1 

tion  of  pomegranate  is  given  with  occasional  success  for 
tapeworm.  It  should  be  followed  in  a  few  hours  by  a 
cathartic.  The  pelletierine  tannate  may  be  administered 
in  doses  of  3  to  8  grains.  It  should  be  given  fasting,  and 
followed  after  twenty  minutes  by  a  full  dose  of  castor  oil. 

Quassia  in  strong  infusion  is  efficaceous  for  pin-worms  in 
the  rectum.  (Oxyuria  vermicularis.)  It  is  injected  into 
the  rectum,  and  held  there  half  an  hour  or  more. 

Santonin  is  the  active  principle  of  the  Levant  wormseed, 
and  is  given  in  doses  of  1/2  to  2  grains.  It  is  best  given  in 
troches  with  sugar,  or  with  calomel,  at  night,  and  followed 
by  castor  oil  or  a  saline  laxative  the  next  morning.  Follow- 
ing its  ingestion,  the  urine  assumes  an  orange-yellow  tinge, 
and  this  should  be  told  the  patient,  lest  he  be  alarmed. 

Spigelia,  or  pinkroot,  is  anthelmintic  against  the  round- 
worm, and  is  in  popular  use  as  a  vermifuge,  administered 
with  senna.  In  large  doses  it  is  an  uncertain  cathartic,  and 
may  produce  serious  symptoms,  as  vertigo,  dimness  of  vis- 
ion, dilated  pupils,  and  convulsions.  This  will  not  occur 
when  it  is  administered  with  a  cathartic,  and  energetically 
propelled  through  the  intestinal  canal.  It  is  usually  given 
in  the  form  of  infusion. 

Thymol  is  a  phenol  contained  in  oil  of  thyme,  occurring  in 
colorless  crystals,  of  aromatic  odor,  pungent  taste,  and  neu- 
tral reaction.  Thymol  is  almost  a  specific  against  the 
uncinaria  Americana,  for  which  it  is  given  in  three  or  four 
doses  of  10  to  30  grains  well  triturated,  in  capsules.  Care 
should  be  taken  that  no  oil  nor  alcoholic  drink  be  ingested 
afterward,  in  order  to  avoid  the  absorption  of  the  thymol, 
and  the  danger  of  poisoning  thereby. 

Tonics. — Drugs  exercising  a  local  tonic  effect  upon  the 
gastric  mucosa  are  included  in  the  stomachics,  which  have 
been  fully  discussed. 

When  stomachics  and  other  forms  of  tonics,  which  exert 
their  effect  upon  only  one  or  more  functions  or  parts  of  the 
body,  are  excluded,  the  number  is  considerably  reduced.  A 
general  tonic  should  restore  energy  and  strength  to  a  debil- 


372  DRUG    THERAPY   IN   DIGESTIVE   DISEASES 

itated  subject  by  a  scarcely  perceptible  stimulation  of  all 
the  vital  functions,  its  effect  being  apparent  in  an  increased 
vigor  of  the  entire  system. 

The  most  typical  of  the  medicinal  agents  which  impart 
general  tone  and  strength  are  strychnin,  cinchona  and  its 
derivatives,  iron,  and  vegetable  bitters;  the  last-named 
accomplishing  their  effects  to  some  extent  through  their 
stomachic  action.  To  these  may  probably  be  added  man- 
ganese, the  glycerophosphites  and  hypophosphites,  phos- 
phorus, cod-liver  oil,  and  perhaps  lecithin. 

It  is  found  that  the  combination  of  several  agents  possess- 
ing an  analogous  action  is  helpful,  the  combined  effects 
proving  more  comprehensive.  Following  are  several  wor- 
thy tonic  prescriptions : 

I^.     Tinct.  nucis  vom 5ii. 

Tinct.  cinchonse  co q.s.  ad.    ^iv. 

SiG. — One  teaspoonful  after  each  meal. 
I^.     Arseni  trioxidi, 

QuinicC  sulphatis, 

Ferri  et  potass,  tart., 

Fiat  pil.  No.  30. 
SiG. — One  pill  after  each  meal. 
I^.     Tr.  ferri 5iv. 

Ac.  phosphorici  dil 5vi. 

Syr.  limonis 5ii- 

Syrupi  simp q.s.  ad.    oiv. 

SiG. — One  teaspoonful  in  water  after  each  meal. 
I^.     Ferri  sulph.  exsic. 

Potass.  ca;rbonatis aa    3ii- 

Syrupi,  q.s.. 

Ft.  pil.  No.  48. 
SiG. — One  pill  after  each  meal,  gradually  increasing  to 

three.      (Blaud's  pill.) 
I^.     Hydrarg.  chlor.  cor gr.  i. 

Liq.  acidi  arsenosi , 3i- 

Tr.  ferri aa    5iv. 

Ac.  hydrochlor.  dil aa   oiv. 

Syr.  simp 3iii. 

Aquae q.s.  ad.    5vi. 

SiG. — Two  teaspoonfuls  in  water  after  meals. 

I^.     Tr.  nucis  vom 3ii. 

Ferri  peptomangani q.s.  ad.  iv. 

SiG. — One  teaspoonful  in  water  after  meals. 


TONICS  373 

This  tonic  is  useful  in  nervous  and  debilitated  subjects: 

I^.    Ext.  sumbul., 

Ferri  sulphatis aa  gr.  xx. 

Asafetidse gr.  x. 

Arseni  triox gr.  ss. 

Ft.  pil.  No.  20. 
SiG. — One  pill  three  times  daily  after  meals. 
I^.     Tr.  condurango 3iii- 

Tr.  nucis  vom 3ii- 

Glycerophos.  co q.s.    iv. 

SiG. — One  teaspoonful  after  meals. 

I^,     Tr.  kolee 5iss. 

Ac.  citrici gr.  xx. 

Sodii  arseniat gr.  i. 

Tr.  cocse q.s.  ad.    5iv. 

SiG. — One  teaspoonful  after  each  meal. 

The  time  is  far  distant,  if  it  ever  comes,  when  some  form 
of  medication  will  not  be  required  by  those  who  are  sick. 
Those  who  preach  from  the  housetops  and  in  the  most  bla- 
tant tones  against  drugs,  are  often  the  first  to  fly  to  the 
physician  for  relief  when  in  real  pain  or  distress.  It  is 
incumbent  upon  every  thoughtful  physician,  therefore,  to 
have  at  his  command  a  definite  and  well-ordered  knowledge 
of  appropriate  medicines  and  their  logical  combinations, 
and,  if  he  will  use  them  with  judgment  in  connection  with 
indicated  hygienic  and  dietetic  measures,  his  efforts  will 
generally  bring  success. 

Patients  are  not,  and  probably  never  will  be  satisfied 
with  advice  alone;  they  expect  some  form  of  medication. 
To  use  a  witty  but  true  aphorism,  "Medicine  sometimes 
cures;  it  often  relieves;  it  always  consoles." 


PART  SECOND 

SPECIAL  DIAGNOSIS  AND  TREATMENT  OF 
DIGESTIVE  DISEASES 


CHAPTER  XV 

NEUROSES,  MOTOR,  SENSORY,  AND 
SECRETORY 

In  the  older  works  on  digestive  diseases,  the  various  neu- 
rotic disturbances  were  given  much  space,  and  through  the 
writings  ran  a  note  of  confidence  in  the  discussion  of  neu- 
roses. As  diagnostic  methods  have  become  more  exact, 
and  as  many  of  these  cases  of  supposed  nervous  disorders 
were  followed  to  surgical  operation,  only  to  find  that  the 
symptoms  rested  upon  definite  and  demonstrable  organic 
changes,  the  tone  has  become  less  certain,  and  we  now 
approach  this  subject,  not  only  with  caution,  but  with  a 
certain  amount  of  trepidation. 

Within  the  last  few  years  chronic  appendicitis,  minus  the 
classic  signs,  has  been  demonstrated  to  be  the  cause  of 
many  cases  of  so-called  hyperchlorhydria.  Irritation  and 
inflammation  of  the  gall-bladder  have  been  recognized  as 
the  origin  of  apparently  gastric  neuroses,  while  former  cases 
of  gastralgia  and  epigastralgia  are  now  referred  to  gastric 
or  duodenal  ulcer.  Many  other  conditions  might  be  cited, 
but  these  are  sufiicient. 

The  term  nervous  indigestion,  nervous  dyspepsia,  and 
psychic  indigestion  should  be  used  with  extreme  care,  and 
only  after  repeated  objective  and  subjective  examinations 
have  enabled  the  physician  to  rule  out  underlying  lesions. 

Cases  of  true  digestive  neuroses  are  almost  invariably 
found  in  the  middle  years  of  life,  among  those  who  think  for 
themselves  and  others.  The  nerve  centers  of  young  chil- 
dren are  less  impressionable  to  emotional  excitants;  while 
in  the  years  past  fifty  or  sixty,  the  waning  digestive  powers, 
in    their    halting    efl:orts    to    produce    the    needed    bodily 

377 


378  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

energy,  have  no  time  to  set  up  fantastic  reflexes.  Diges- 
tive troubles  in  the  two  extremes  of  Hfe  are  generally  due  to 
dietetic  errors,  while  in  old  people  organic  and  malignant 
maladies  play  an  important  part. 

Older  estimates  placed  50  to  75  per  cent,  of  those  suffer- 
ing from  indigestion  among  the  neuroses.  These  figures 
were  compiled  before  the  days  of  modern  surgery,  of  X-ray 
examination,  and  of  systematic  investigation  of  the  stom- 
ach-contents and  feces.  Present-day  writers  estimate  the 
percentage  of  purely  nervous  indigestion  at  about  3  to  5 
per  cent,  in  hospital  cases,  and  possibly  12  or  15  per  cent, 
in  private  practice.  Lockwood  suggests  that  an  additional 
10  per  cent,  be  added,  if  there  be  included  patients  with  the 
enteroptotic  habitus  and  well-developed  visceral  ptoses. 
My  own  records  would  point  to  between  5  and  8  per  cent,  of 
perhaps  uncomplicated  neuroses,  and  generally,  in  calling 
any  digestive  affection  a  pure  neurosis,  I  do  so  with  a  mental 
reservation. 

Diagnosis.^ — The  diagnosis  of  nervous  indigestion  should 
never  be  made  until  all  diagnostic  methods  have  been 
exhausted.  I  have  so  often  had  patients  to  come  into  my 
office  bringing  with  them  this  diagnosis,  and  learning  that 
no  test-meal  had  been  taken  or  analyzed,  nor  a  thorough 
physical  examination  made  of  the  heart  and  lungs. 

A  good  rule  is  to  arrive  at  the  diagnosis  of  nervous  indi- 
gestion or  other  of  the  digestive  neuroses  by  the  process  of 
exclusion,  eliminating  one  by  one  underlying  organic  lesions. 

The  following  rules  are  adapted  from  the  recent  excellent 
work  of  Lockwood : 

( 1 )  A  diagnosis  of  nervous  indigestion  should  not  be  made 
in  the  presence  of  more  than  30  c,c.  of  fluid  in  the  fasting 
stomach,  the  fluid  giving  a  strong  reaction  for  hydrochloric 
acid.  Hypersecretion  is  generally  an  expression  of  pyloric 
stenosis,  organic  or  spasmodic,  and  this  is  due  to  an  organic 
cause. 

(2)  A  diagnosis  of  nervous  indigestion  should  not  be  made 
in  the  presence  of  persistent  hyperacidity  accompanied  by 


NERVOUS    INDIGESTION  379 

epigastric  pain.  Nervous  hyperchlorhydia  may  occur,  but 
is  not  accompanied  by  either  pyrosis  or  pain.  The  asso- 
ciation of  either  of  these  latter  symptoms  should  suggest 
an  organic  origin  for  the  complaint. 

(3)  Achylia  gastrica  may  be  of  nervous  origin,  but  this  is 
not  probable  when  serious  motor  error  is  in  evidence. 
Achylia  with  food-stagnation  is  strongly  suggestive  of 
cancer  of  the  stomach. 

(4)  Achylia  gastrica,  accompanied  by  pain  or  vomiting, 
indicates  an  underlying  organic  cause. 

(5)  The  diagnosis  of  nervous  indigestion  should  not  be 
made  when  recognizable  food  remains  are  repeatedly  found 
in  the  fasting  stomach.  Under  the  influence  of  fear,  ner- 
vous shock,  or  vicissitudes  of  temperature  the  motor  func- 
tions may  be  temporarily  interfered  with,  but  this  would 
not  be  the  case  permanently. 

(6)  The  diagnosis  of  nervous  indigestion  should  not  be 
made  when  epigastric  distress  or  pain  occurs  regularly  at  a 
definite  time  after  eating.  The  very  fact  of  this  disturbance 
coming  on  at  a  definite  time  argues  against  a  neurosis. 

(7)  The  diagnosis  of  nervous  indigestion  should  not  be 
made  when  one  symptom  alone  persists,  without  other  evi- 
dences of  nervous  instability.  The  presence  of  one  definite 
symptom  in  itself  presupposes  an  organic  cause. 

(8)  The  physician  should  be  on  the  qui  vive  for  drug  ad- 
dictions, for  these  habitues  can  sometimes  present  a  syn- 
drome of  symptoms  that  will  puzzle  the  most  experienced. 

(9)  The  diagnosis  of  nervous  indigestion  should  not  be 
made  in  persons  over  forty  or  forty-five,  in  whom  indiges- 
tion is  a  new  symptom.  Such  patients  are  usually  develop- 
ing a  serious  systemic  or  malignant  disorder. 

(10)  Finally,  digestive  neuroses  and  organic  diseases  may 
be  concomitant,  and  the  presence  of  either  need  not  exlcude 
the  other. 

In  diagnosing  a  digestive  neurosis  the  personality  of  the 
patient  must  be  taken  into  account.  The  symptoms  are 
shifting,  variable,  and  evanescent.     The  clinical  symptoms 


380  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

bear  but  little  relation  to  the  food  ingested,  while  slight  dis- 
turbances produce  the  most  bitter  complaining.  Such  pa- 
tients invariably  improve  when  their  occupation  or  environ- 
ment is  changed,  or  a  vacation  is  enjoyed.  During  a  vaca- 
tion trip  or  a  respite  from  daily  cares  these  people  find  that 
they  can  eat  any  ordinary  food  without  discomfort,  but 
when  they  again  take  up  the  daily  burdens,  their  symptoms 
promptly  return. 

One  caution  may  be  here  inserted :  Under  the  influence  of 
shock  or  powerful  emotion  symptoms  of  organic  disease 
sometimes  disappear  for  a  while.  Later,  after  the  emotions 
have  resumed  their  normal  tenor  the  symptoms  naturally 
reappear.  Patients  also  with  serious  organic  diseases  may 
be  greatly  influenced  for  better  or  worse  by  extraneous 
circumstances. 

Several  therapeutic  tests  may  be  tried,  and  a  prompt 
response  to  either  argues  in  favor  of  a  neurosis,  within 
reasonable  limitations. 

First,  a  gastric  sedative  may  be  given  for  five  to  seven 
days,  and  the  results  noted.  The  prescription  containing 
chloral  and  strontium  bromide  is  suitable  for  this  test,  and 
if  decided  improvement  ensues,  it  is  a  strong  point  in  favor 
or  a  neurosis. 

Second,  if  the  patient,  when  on  a  vacation,  finds  that  he 
can  eat  without  inconvenience  ordinary  articles  of  food,  but 
that  even  a  light  diet  disagrees  when  he  is  at  home  or  at 
work,  some  neurosis  may  be  suspected. 

Third,  many  nervous  and  emotional  symptoms  in  run- 
down and  emaciated  invalids  are  due  to  starvation  alone, 
and  disappear  when  the  body  is  strengthened  by  adequate 
food.  These  sufferers  are  nearly  all  on  a  "diet,"  in  some 
instances  self-imposed ;  in  others  a  rigorous  course  of  food- 
deprivation  has  been  instituted  long  previously,  and  kept 
up  under  a  mistaken  idea  that  the  disease  was  being 
"starved  out."  They  have  developed  a  sitophobia,  or 
fear  of  food,  and  this  fear  is  a  part  of  the  nervous  picture. 
Under  generous  feeding,  reinforced  by  whoselome  psycho- 


MOTOR    NEUROSES  38 1 

therapy,  the  nervous  manifestations  in  this  class  of  patients 
generally  disappear. 

MOTOR  NEUROSES 

Hypermotility. — This  means  an  abnormal  rapidity  in  the 
movement  of  the  stomach,  resulting  in  too  hasty  evacua- 
tion. Sometimes  the  stomach  is  found  empty  in  a  few  min- 
utes after  the  ingestion  of  a  meal.  Combined  with  this 
may  be  achylia  gastrica  with  defective  closure  of  the  py- 
lorus, the  latter  being  due  to  absence  of  the  acid,  or  simple 
lack  of  tone  in  the  outlet.  The  diagnosis  is  made  by  means 
of  a  test-meal.  The  treatment  consists  of  general  tonics, 
dilute  acid,  and  faradic  electricity  applied  over  the  stomach. 

Peristaltic  Unrest  of  the  Stomach. — This  complex  of 
symptoms  brings  about  increased  peristaltic  motions  of  the 
stomach,  and  does  not  often  occur  as  a  pure  neurosis. 
These  movements  may  be  easily  observed  in  thin  patients 
with  flabby  abdominal  walls,  and  they  are  often  accompa- 
nied by  rolling  and  gurgling  sounds,  which  can  be  heard 
some  distance  from  the  patient.  This  condition  is  often 
present  in  stenosis  of  the  pylorus,  and  should  not  be  classed 
as  a  neurosis  unless  the  former  can  be  excluded. 

Treatment  comprises  constitutional,  dietetic,  and  psy- 
chic means.  The  body  should  be  well  nourished  by  bland 
and  unirritating  food,  but  not  too  much  at  a  time,  and  the 
evening  meal  should  be  specially  light.  Hydrotherapy 
holds  a  useful  place,  either  warm  or  cold  compresses  being 
indicated,  as  the  patient  wishes.  External  faradic  elec- 
tricity may  be  employed,  while  a  brief  "rest  cure"  is  of 
benefit.  The  bromide  of  strontium  dissolved  in  the  elixir 
of  the  valerianate  of  ammonia,  or  concentrated  tincture  of 
passiflora  incarnata  may  be  given.  The  use  of  codein  or 
morphine,  as  recommended  by  some,  is  to  be  avoided. 

Peristaltic  Unrest  of  the  Intestines. — This  condition 
consists  of  marked  rotary  or  rolling  movements  of  the  intes- 
tines, so  that  their  vermicular  motion  is  often  visible.     It 


382  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

is  usually  seen  in  hysterical  or  hypochondriacal  patients, 
though  it  is  occasionally  concomitant  with  organic  troubles. 

Clinically  there  are  rolling,  gurgling  noises  in  the  abdo- 
men, easily  heard,  generally  without  pain,  but  most  embar- 
rassing to  the  patient.  Stenosis  of  the  small  or  large  intes- 
tine must  be  excluded. 

Treatment. — This  is  much  like  that  of  gastric  unrest,  and 
consists  of  measures  to  tone  up  the  body,  to  quiet  the 
nerves,  and  to  permit  a  maximum  of  food  with  a  minimum 
of  work  for  the  bowels. 

Nervous  Diarrhea. — This  exaggerated  peristaltic  move- 
ment may  occur  in  both  the  large  and  small  intestine, 
while  an  increased  transudation  of  fluid  may  be  present  due 
to  nervous  influences.  The  treatment  is  the  same  as  in 
ordinary  diarrhea,  plus  attention  to  underlying  nervous 
conditions. 

Cardiospasm.— In  this  disorder  the  cardiac  orifice  of 
the  stomach  contracts  at  the  point  of  its  junction  with  the 
esophagus,  and,  with  a  spasmodic  closure,  prevents  any 
food  from  entering  the  stomach.  This  spasm  is  probably 
due  to  some  irritation  of  the  pneumogastric  nerve. 

Diagnosis. — This  may  be  made  by  observation  of  both 
objective  and  subjective  symptoms.  When  a  bougie  is 
introduced,  it  is  seized  by  the  cardia,  retained  by  the  con- 
traction a  while,  and  then,  after  a  period  of  waiting,  the 
spasm  relaxes.  An  organic  obstruction  does  not  exhibit 
this  symptom.  The  diagnosis  may  be  confirmed  by  an 
X-ray  examination. 

Treatment.- — -This  is  mainly  the  management  of  under- 
lying neurotic  states.  Psychotherapy  is  important,  so 
that  the  patient  may  swallow  deliberately  without  that  ele- 
ment of  fear  which  precipitates  the  spasm.  He  should  first 
perform  the  act  of  deglutition  without  food  in  the  mouth, 
after  which  he  should  begin  to  eat  very  slowly.  His  atten- 
tions should  be  diverted  from  his  esophagus,  and  his  meals 
should  be  taken  under  pleasant  surroundings. 

One  or  two  teaspoonfuls  of  liquid  albolene  may  be  allowed 


PYLOROSPASM  383 

to  trickle  down  the  esophagus  just  before  eating,  or  oHve  oil 
may  be  given,  if  preferred. 

Dilatation  has  been  advised,  and  Dr.  Sippy  has  devised 
a  practical  instrument  for  the  purpose.  In  dilating  the 
spasm,  the  stretching  process  should  be  continued  for  quite 
a  while,  and  the  orifice  should  be  widely  dilated.  Large 
esophageal  sounds  or  bougies  may  be  introduced,  being  left 
in  situ  for  fifteen  to  thirty  minutes.  Electrotherapy  is 
sometimes  beneficial,  but  probably  by  its  psychic  influence. 

Pylorospasm. — This  neurosis  is  of  comparative  fre- 
quency, and  its  differentiation  between  mechanical  obstruc- 
tion and  spasm  is  sometimes  difficult. 

Diagnosis.' — -This  is  best  made  with  either  the  duodenal 
bucket  or  tube.  The  clinical  picture  must  be  taken  into 
account.  If  it  is  found  that  at  times  the  bucket  penetrates 
the  duodenum,  as  evidenced  by  the  presence  of  duodenal 
contents,  while  at  other  times  it  fails  to  leave  the  stomach; 
and  if,  in  addition  there  is  nervous  pain  with  increased  gas- 
tric peristalsis  and  perhaps  vomiting,  the  diagnosis  of  pyloro- 
spasm may  be  made. 

Treatment. — ^This  is  embraced  in  the  external  applica- 
tion of  heat,  the  internal  administration  of  nerve-sedatives 
and  lubricants,  and  suitable  hygienic,  dietetic  and  psychic 
measures.  Einhorn  has  used  his  pyloric  dilator  with  con- 
siderable success.  Oil,  taken  on  the  fasting  stomach,  as 
advocated  by  Cohnheim,  in  connection  with  means  to 
relieve  hyperacidity,  may  be  used  with  advantage. 

Rumination  (Merycism). — This  consists  in  voluntarily 
bringing  up  food  in  small  quantities,  so  that  it  may  be 
remasticated  and  again  swallowed.  Rumination  occurring 
soon  after  meals  allows  the  food  to  retain  its  original  taste, 
but  later  on  brings  up  the  food  either  sour  or  bitter.  This 
is  more  common  in  men  than  in  women,  there  being  only 
ten  women  in  one  hundred  and  forty -five  cases,  as  reported 
by  Presslich. 

The  mechanism  of  rumination  is  imperfectly  understood, 
and  is  supposed  to  depend  upon  relaxation  of  the  cardia. 


384  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

Heredity  has  been  thought  to  play  a  part;  also  imitation, 
for  in  one  instance  a  ruminating  governess  discovered  later 
the  habit  in  two  of  her  pupils. 

Treatment. — The  patient  should  be  forced  to  eat  slowly, 
and  to  fight  against  and  suppress  the  habit.  Bitter  or 
bad-tasting  medicines  are  of  aid,  for  a  bad  taste  in  rumina- 
tion tends  to  discourage  it.  Psychotherapy  plays  a  most 
important  part  in  the  treatment. 

SENSORY  NEUROSES 

Gastralgia. — This  condition  is  discussed  under  various 
names,  some  of  them  being  cardialgia,  gastrodynia,  or  neu- 
ralgia of  the  stomach.  It  is  often  found  in  individuals  of 
unstable  nervous  poise,  but  a  positive  diagnosis  of  this 
neurosis  should  be  made  with  great  caution,  and  only  after 
logical  exclusion  of  organic  affections,  underlying  or  even 
remote. 

The  patient  complains  bitterly  of  pain  in  the  epigas- 
trium, and  the  location  of  the  pain  is  really  exterior  to  the 
stomach.  The  paroxysms  of  pain  come  on  at  irregular 
intervals,  may  last  from  a  few  hours  to  several  days,  and 
bear  little  relation  to  food  ingested.  The  attacks  often 
follow  nervous  stress  or  any  sudden  emotion.  During 
the  attack  there  is  hyperesthesia  over  the  epigastrium, 
while  eructations  may  be  frequent  and  explosive. 

Treatment. — This  should  consist  of  means  to  improve 
the  general  condition  between  the  attacks,  and  embraces 
the  usual  means  to  accomplish  this  end.  During  the  attack 
the  patient  will  demand  active  measures,  and  the  physician 
may  give  a  hypodermic  of  morphine  with  atropine,  while 
hot  applications  should  be  liberally  applied  to  the  epigas- 
trium. Only  in  rare  instances  should  morphine  or  any  other 
potent  anodyne  be  left  with  the  patient  to  take  as  he  desires, 
for  such  individuals  readily  acquire  the  drug  habit.  Many 
are  the  abject^  slaves  to-day  whose  bonds  were  first  placed 
by  some  overkind  physician,  and  who  by  the  continued  use 
of  some  narcotic  drug  riveted  those  bonds  themselves. 


SENSORY    NEUROSES  385 

Occasionally  5 -grain  doses  of  phenacetine  give  relief,  and 
do  not  tend  to  cause  any  habit.  A  most  valuable  prescrip- 
tion consists  of  equal  parts  of  Hoffman's  anodyne  and 
fluid  extract  of  viburnum  opulus,  or  cramp  bark.  This 
combination  may  be  given  in  teaspoonful  doses  in  hot 
water  every  half  hour  till  relief  is  obtained.  Intelli- 
gent hydrotherapy,  also,  is  beneficial  in  this  distressing 
complaint. 

Hyperesthesia  Gastrica. — This  abnormal  sensitiveness 
often  develops  without  an  apparent  cause,  and  leaves  as 
quickly  as  it  came.  The  tenderness  is  most  apparent  to 
heat  or  cold,  and  in  some  individuals  appears  after  certain 
seemingly  harmless  articles  of  food  are  taken,  not  leaving 
until  the  stomach  is  empty.  Like  other  of  the  neuroses,  it 
is  most  often  seen  in  those  with  unstable  nerves. 

Treatment. — The  diet  list  should  be  scrutinized  and 
articles  left  off  that  cause  pain,  but  care  should  be  exercised 
that  other  equally  nourishing  foods  are  put  in  their  place, 
lest  malnutrition  supervene.  Regular  diet  should  be  re- 
sumed as  soon  as  possible,  or  the  patient  may  become  mor- 
bidly introspective. 

Nitrate  of  silver  in  8-grain  doses,  diluted  in  one-fourth 
glass  of  water  may  be  given  four  times  daily.  This  should 
be  kept  up  only  a  few  days,  however.  A  combination 
of  strontium  bromide  with  sodium  bicarbonate  and  bismuth 
subcarbonate  is  sometimes  most  efficaceous.  If  between 
meals  there  is  undue  burning,  calcined  magnesia  in  tea- 
spoonful  doses  may  be  taken  dry  or  in  water. 

Bulimia. — This  term,  sometimes  called  hyperorexia, 
means  a  condition  in  which  the  sense  of  hunger  is  abnor- 
mally augmented.  In  some  manifestations  of  bulimia  the 
patient's  hunger  is  so  imperative  in  its  demands,  that  he 
becomes  almost  frantic  if  he  cannot  obtain  something  to 
eat.  It  may  be  associated  with  gastric  ulcer,  or  cancer, 
hyperacidity  or  neurasthenia,  or  may  be  a  primary  affec- 
tion.    This  symptom  is  occasionally  a  precursor  of  paresis. 

Treatment. — The  cause,  if  possible,  should  be  discovered 

25 


386  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

and  removed.  The  patient  should  arrange  to  always  have 
food  at  hand  so  that  something  may  be  eaten  as  soon  as  the 
attack  begins.  General  tonic  and  hydrotherapeutic  meas- 
ures should  be  inaugurated,  and  all  the  influences  of  psy- 
chotherapy brought  to  bear. 

Bulimia  must  be  differentiated  from  akoria,  which  is 
loss  of  the  sense  of  satiety.  Akoria  is  generally  the  mani- 
festation of  a  deep-seated  nervous  lesion  which  demands 
special  therapy. 

Anorexia  Nervosa. — This  is  an  aversion  or  distaste  for 
food  without  any  tangible  reason.  Often  the  patient  can- 
not explain  why,  but  insists  that  any  form  of  food  is  repug- 
nant. It  may  be  brought  on  by  worry,  anxiety  or  fright, 
and  is  generally  found  in  neurasthenics,  or  chlorotic  girls. 

Treatment.— This  should  be  strongly  suggestive,  and  the 
patient  should  be  placed  where  facilities  are  at  hand  for 
giving  food  forcibly.  Strenuous  efforts  should  be  put  forth 
to  induce  the  invalid  to  eat,  and  these  failing,  the  food 
should  be  given  by  gavage,  by  the  stomach-tube,  and  by 
enema.  After  a  few  treatments  of  this  sort  the  patient  will 
find  that  eating  is  easier,  and  will  generally  accept  the  inev- 
itable. The  rest  cure  with  forced  alimentation,  where 
practicable,  is  nearly  always  specific.  But  few  of  these  neu- 
rotics can  be  cured  under  home  surroundings,  and  the  phy- 
sician should  be  chary  in  attempting  such  a  case  unless  he 
can  place  the  patient  under  such  environment  that  complete 
control  can  be  obtained. 

Stomachics— the  more  bitter,  the  better — are  sometimes 
of  benefit,  but  medicinal  treatment  has  but  a  small  place  in 
the  treatment  of  this  trying  malady. 

Hyperkoria,  or  increased  sense  of  satiety,  when  nervous, 
may  be  classed  in  the  same  category  as  anorexia  nervosa, 
and  be  treated  in  the  same  manner. 

Eye -strain  and  Gastric  Neuroses. — Dr.  George  M.  Gould 
was  practically  the  first  to  call  attention  to  the  connection 
between  eye-strain  and  various  gastric  neuroses.  There  is 
no  set  rule  for  diagnosing  a  connection,  but  in  obscure  cases 


SECRETORY   NEUROSES  387 

the  element  of  eye-strain  should  always  be  eliminated  before 
the  physician  can  be  sure  of  his  ground.  I  make  it  a  rou- 
tine practice  to  have  the  eyes  of  every  nervous  patient  inves- 
tigated, and  not  infrequently  the  problem  is  solved  and  the 
remedy  applied  by  the  oculist. 

SECRETORY  NEUROSES 

Hyperchlorhydria. — This  is  applied  to  that  condition  of 
the  gastric  secretions  in  which  the  quantity  of  the  gastric 
juice  is  normal,  but  the  percentage  of  free  hydrochloric 
acid  higher  than  normal  (Aaron) . 

While  hyperchlorhydria  as  a  pure  neurosis  is  no  doubt  a 
clinical  entity,  the  attitude  of  the  medical  profession  is 
becoming  more  skeptical,  and  some  of  the  surgeons  go  so 
far  as  to  say  that  there  is  never  any  decided  or  lasting  hyper- 
chlorhydria without  the  presence  of  an  organic  lesion. 

A  neurotic  hyperacidity  is  a  secretory  neurosis  dependent 
upon  the  abnormal  stimulation  or  inhibition  of  certain  nerve 
trunks  leading  to  the  stomach.  One  point  that  causes  some 
confusion  is  the  fact  that  the  clinical  symptoms  of  either 
primary  hyperacidity  or  that  brought  about  by  some 
underlying  and  irritating  lesion  are  practically  the  same. 
Occasionally  there  are  few  or  no  subjective  symptoms, 
dependent,  no  doubt,  upon  a  difference  in  the  sensitiveness 
of  the  gastric  mucosa.  There  are  some  individuals  with  a 
high  degree  of  hyperchlorhydria  who  make  little  or^  no 
complaint. 

This  neurosis  is  found  chiefly  in  young  adults,  though 
neither  the  young  nor  aged  are  entirely  exempt.  It  is  most 
often  encountered  in  nervous  individuals,  those  suffering 
from  neurasthenia,  melancholia,  psychasthenia,  or  among 
those  who  are  laboring  under  the  stress  of  grief,  worry  or 
mental  overwork. 

There  are  no  characteristic  pathologic  changes  in  simple 
hyperchlorhydria. 

Diagnosis. — This  trouble,  unless  generated  by  some  vio- 


388  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

lent  mental  storm,  develops  gradually.  The  patient  feels 
an  uneasy  sensation  at  a  rather  definite  time  after  meals, 
the  time  depending  to  some  extent  on  what  has  been  eaten. 
When  all  is  well  mentally,  and  the  mind  is  diverted,  this 
discomfort  is  noticed  less  or  not  at  all.  The  sensations  of 
distress  or  pain  vary  from  one  of  burning  in  the  epigastrium 
to  severe  cramping  spells,  the  latter  being  probably  caused 
by  pylorospasm  brought  on  by  the  impingement  of  the 
extremely  acid  chyme  against  that  outlet.  Connected  with 
this  there  may  be  headache,  excessive  nervousness,  dread 
of  eating  and  generally  constipation.  Many  of  these 
patients  find  that  they  can  ease  the  pain  by  eating  some 
light,  bland  article  while  the  hyperacidity  is  most  painful. 
The  appetite  is  generally  good  in  these  patients,  and,  unless 
they  are  on  a  limited  diet,  or  have  developed  an  exhausting 
sitophobia,  they  appear  fairly  well  nourished. 

Upon  physical  examination  the  epigastric  region  is  gen- 
erally sensitive  to  light  pressure,  but  gentle  and  firm  pres- 
sure often  affords  a  measure  of  relief. 

The  diagnosis  can  only  be  confirmed  by  chemic  examina- 
tion of  the  stomach  contents,  as  the  symptoms  alone,  while 
strongly  suggestive,  are  not  infallible.  The  free  hydro- 
chloric acid  will  be  found  to  range  from  40  to  100  or  even 
more,  though  the  macroscopic  appearance  of  the  test-meal 
is  about  normal.  It  is  well  to  make,  if  possible,  several 
tests,  for  it  will  be  noted  that  the  hyperacidity  will  vary 
according  to  the  patient's  mental  status. 

To  make  a  positive  diagnosis  of  hyperacidity  as  a  neurosis 
requires  the  most  serious  thought,  for  the  whole  course  of 
treatment  depends  upon  the  decision,  and  a  mistake  may 
lose  for  the  patient  much  precious  time,  which  could  be 
utilized  to  better  advantage  otherwise. 
-  The  following  diagnostic  rules  are  adapted  from  Lock- 
wood: 

(i)  Do  not  make  a  diagnosis  of  hyperacidity  until  all 
organic  lesions  are  excluded,  and  even  then  be  prepared 
perhaps  to  change  the  diagnosis  under  later  developments. 


SECRETORY    NEUROSES  389 

(2)  Do  not  make  a  diagnosis  of  hyperacidity  without 
examination  of  the  fasting  stomach  with  the  tube.  The 
presence  of  acid  fluid  or  of  food  remains,  or  any  considerable 
amount  of  acid  mucus  should  exclude  the  diagnosis. 

(3)  Do  not  make  a  diagnosis  of  hyperacidity  simply 
because  the  patient  is  nervous  or  neurotically  sensitive. 
Individuals  may  be  just  as  nervous  in  the  presence  of 
organic  disease  as  without  it. 

(4)  Do  not  make  a  diagnosis  of  hyperacidity,  should  the 
previous  clinical  history  suggest  attacks  that  may  point  to 
appendicular  or  gall-bladder  disease,  or  should  the  results 
of  physical  examination  be  such  that  these  lesions  are 
probable. 

(5)  Do  not  make  a  diagnosis  of  hyperacidity  in  cases 
accompanied  by  acute  epigastric  pain,  whether  dependent 
or  not  upon  the  taking  of  food.  Especially  should  this  be 
avoided,  if  the  pains  occur  at  a  definite  period  after  eating 
and  are  not  influenced  in  their  onset  by  emotional  causes. 

(6)  Do  not  make  a  diagnosis  of  hyperacidity  if  hemor- 
rhage from  the  stomach  or  intestines  be  present,  either 
visible  or  occult. 

(7)  Do  not  make  a  diagnosis  of  hyperacidity  in  cases 
accompanied  by  repeated  vomiting,  especially  if  the  vomit- 
ing be  of  the  abundant  type  indicative  of  hypersecretion. 

(8)  Do  not  make  a  diagnosis  of  hyperacidity  when  the 
symptoms  occur  at  a  time  when  the  stomach  is  empty. 

(9)  Do  not  make  a  diagnosis  of  hyperacidity  in  the 
event  of  the  test  breakfast  settling  into  layers,  the  super- 
natant fluid  being  more  than  twice  the  depth  of  the  sedi- 
mentary layer.  These  are  the  cases  of  alimentary  hyper- 
secretion with  which  hyperacidity  as  a  neurosis  should  not 
be  confounded. 

(10)  Do  not  make  a  diagnosis  of  hyperacidity  in  cases 
attended  with  anorexia,  with  nausea,  with  advancing  ane- 
mia, and  with  progressive  loss  of  flesh,  especially  if  the 
patient  be  of  adult  years,  and  with  previously  good 
digestion. 


390  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

(ii)  Do  not  make  a  diagnosis  of  hyperacidity,  without 
mental  reservation,  in  any  patient  over  forty-five  who  has 
recently  developed  the  complaint. 

(12)  Do  not  in  any  case  make  a  diagnosis  of  hyperacidity 
without  one  or  more  gastric  analyses. 

Treatment. — Hyperchlorhydria  is  in  the  main  a  symp- 
tom, and  its  treatment  must  be  in  the  main  symptomatic. 
After  the  physician  has  intelligently  eliminated  the  possible 
organic  causes,  he  may  then  set  about  treating  the  neurosis 
with  a  fair  degree  of  confidence. 

The  chemic  indications  are  naturally  those  of  an  alkaline 
nature,  and  the  combinations  will  depend  to  an  extent  on 
the  state  of  the  bowels.  These  powders  may  be  taken  at 
about  the  time  after  meals  when  the  first  symptoms  of  dis- 
comfort appear,  and  repeated  at  half-hour  intervals  until 
relief  is  obtained.  If  the  powder  contains  a  laxative  ingre- 
dient, it  is  well  to  give  the  patient  two  powders,  one  of  which 
does  not  contain  the  laxative,  instructing  him  to  use  the 
latter  powder  when  repetition  is  necessary. 

The  following  have  been  of  service,  and  the  ingredients 
may  be  proportioned  to  meet  individual  cases  and  con- 
ditions : 

I^.     Magnesice  ustae, 

Bismuthi  subcarbonatis aa    5iv. 

Sodii  bicarbonatis §i. 

SiG. — One  teaspoonful  dry  or  in  water  one  hour  after  meals. 
I^.     Magnesise  ustae, 

Sodii  bicarb aa   §i. 

Pv.  rhei, 

Sacch.  lactis aa    5ii- 

SiG. — One  teaspoonful  one  or  two  hours  after  meals. 
I^.     Cerii  oxalatis, 

Bismuthi  subcarb aa   5iv. 

Magnesia  ustae 5iii- 

Sodii  bicarb 5i- 

SiG. — One  teaspoonful  after  meals. 

I^.     Orthoformi 5i- 

Bismuthi  subcarbonatis 5ii- 

Misturas  rhei  et  sodii q.s.  ad.    ohi. 

SiG. — One  teaspoonful  in  a  little  water  as  needed. 


TREATMENT    OF    SECRETORY    NEUROSES  39 1 

Alkaline  waters  are  practically  useless,  though  water  in 
abundance  dilutes  the  stomach  contents,  and  aids  the  speedy 
evacuation  of  that  viscus. 

Belladonna  and  atropin  have  been  recommended,  though 
their  efficacy  is  problematical.  The  dryness  of  the  fauces 
and  general  discomfort  following  the  administration  of 
atropin  cannot  be  atoned  for  by  any  assumed  benefit. 
Extract  of  belladonna  in  1/50  grain  granules,  given  half 
an  hour  before  meals,  has  seemed  of  service.  This  drug 
may  be  given  up  to  one-twentieth  of  a  grain  three  times 
daily;  more  than  that  is  not  advisable.  In  the  very  small 
doses  it  inhibits  to  a  Hmited  extent  the  excessive  flow  of 
the  gastric  juice. 

Nitrate  of  silver,  in  1/4-grain  doses,  given  in  a  capsule  or 
in  water  three  times  daily  has  been  recommended.  It  has 
not  proved  satisfactory  in  my  hands. 

Gastric  Lavage. — This  question  of  gastric  lavage  in 
hyperchlorhy dria  is  sub  judice  at  present .  Whether  the  pos- 
sible astringent  and  sedative  effects  of  the  lavage  may  not 
be  overcome  by  the  irritation  of  the  tube  and  by  strongly 
centering  the  patient's  mind  on  his  stomach  is  a  debatable 
question. 

I  have  employed  with  apparent  benefit  a  lavage  of 
nitrate  of  silver  in  warm  water,  i :  5000.  This  is  preceded 
by  a  generous  lavage  of  a  warm  saline  solution.  Stronger 
solutions  of  nitrate  of  silver  are  not,  in  my  opinion,  advis- 
able, though  the  strength  of  1:1500  is  recommended  by 
one  good  authority.  Lavage  on  alternate  days  is  often 
enough. 

Rosenheim,  of  Berlin,  recommends  aluminum  salicylate 
in  doses  of  a  half  to  one  teaspoonful  in  water  a  half  to  one 
hour  before  meals.  This  is  in  the  market  under  the  name 
of  Neutralon  (Kaulbaum)  and  may  be  tried  in  obstinate 
cases. 

Goodman,  of  Philadelphia,  advocates  the  use  of  i  ounce 
of  a  3  per  cent,  solution  of  hydrogen  peroxide  in  a  glass  of 
water.     This    affords   much   reHef   from   the   heart-burn. 


392  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

though  it  exercises  but  Httle  permanent  effect  upon  the 
hyperacidity. 

OHve  oil  has  been  recommended,  owing  to  its  supposed 
inhibitory  effect  upon  the  gastric  secretion.  A  tablespoon- 
ful  may  be  given  half  an  hour  before  meals.  If  this  is  not 
well  borne,  a  teaspoonful  of  the  aromatic  liquid  albolene 
seems  to  answer  quite  as  well. 

Dietetic  Management  of  Hyperchlorhydria. — Clinical 
observation  has  demonstrated  that  those  articles  of  food 
which  bind  large  quantities  of  hydrochloric  acid  are  the 
best  borne,  and  exercise  the  most  desirable  influences  upon 
the  overworking  oxyntic  cells.  The  burning  feeling  of 
distress  or  pain  is  relieved  by  the  administration  of  albu- 
minous food,  while  carbohydrates,  if  given  in  any  quantity, 
cause  discomfort.  The  diet,  therefore,  is  of  the  greatest 
importance. 

All  articles  which  tend  to  overstimulate  the  secretory 
glands  of  the  stomach  should  be  forbidden.  Such  articles 
comprise  acids,  spices,  pepper,  mustard,  pickles,  horseradish, 
olives,  acid  fruits,  beer,  wine,  whiskey,  and  the  various 
tasty  condiments  and  sauces. 

The  food  should  be  rich  in  albumen,  such  as  chops,  steak, 
roast  beef  and  mutton,  game,  eggs,  milk,  oysters  and  fish. 
None  of  these  should  be  fried,  however,  as  the  frying  tends 
to  coagulate  the  albumen  making  them  much  harder  to 
digest.  Bread  and  butter  can  be  taken,  the  former  in 
moderation.  Green  vegetables,  such  as  spinach,  tender 
mustard  or  turnip  "greens,"  asparagus,  lettuce,  peas  and 
string  beans,  potatoes,  rice  and  other  cereals,  should  be  given 
in  small  quantity.  It  is  best,  though,  for  these  to  be  taken 
in   conjunction   with   large  amounts  of  albuminous  food. 

Alcohol  in  all  forms  should  be  interdicted.  It  is  not 
always  practicable  to  stop  the  use  of  coffee  or  tea,  but  these 
beverages  should  be  allowed  in  small  amounts  and  quite 
weak. 

Kemp  has  been  pleased  with  the  use  of  gelatin,  employing 
2  or  3  ounces  of  5  to  lo  per  cent,  gelatin  solution,  flavored 


TREATMENT    OF    HYPERCHLORHYDRIA  393 

with  a  pinch  of  sugar  or  a  little  vanilla,  and  given  midway 
between  meals.  The  value  of  egg-albumin  and  cocoa  is 
marked.  Starchy  foods  that  have  been  well  dextrinized, 
as  zwieback,  dry  toast,  and  some  of  the  dextrinized  cereals, 
are  more  readily  digested. 

Considerable  water  should  be  drunk  with  meals,  unless 
advanced  atony  complicates  the  case. 

Fats,  such  as  butter  and  cream  are  of  value.  Since  the 
carbohydrates  are  necessarily  limited,  the  fats  are  available 
for  the  supply  of  required  calories;  furthermore,  fats  lessen 
acidity,  and  perhaps  the  irritable  tendency  of  the  gastric 
mucous  membrane. 

It  is  often  helpful  in  the  dietetic  management  of  hyper- 
chlorhydria  to  give  three  additional  feedings  at  a  time  after 
the  regular  three  daily  meals.  The  extra  feedings  may 
consist  of  lactone  buttermilk  (very  fresh) ,  bouillon,  a  sand- 
wich, milk,  raw  eggs  (especially  the  whites),  and  milk,  with 
crackers  or  bread  and  butter.  From  this  assortment  of 
edibles,  one  can  select  an  appetizing  lunch. 

For  practical  purposes  an  improvement  in  nutrition  and 
weight,  even  though  slight,  should  be  sought  in  additiomto 
the  amelioration  of  the  distressing  symptoms.  This  is 
especially  desirable  in  those  who  have  been  reduced  in 
weight  and  strength  by  a  too  limited  diet.  The  scales 
should  be  brought  into  frequent  requisition,  and  even 
though  an  apparently  sufficient  number  of  calories  are 
ingested,  if  the  weight  does  not  show  improvement,  the 
regimen  should  be  increased  in  some  manner. 

I  do  not  believe  that  a  pure  neurotic  case  of  hyperchlorhydria 
was  ever  cured  by  a  limited  and  prolonged  diet,  and  in  cases  of 
doubt,  the  physician  will  find  it  safer  and  more  satisfactory  to 
allow,  and  perhaps  to  insist  upon,  a  liberal  daily  intake  of 
food. 

Hygienic,  hydrotherapeutic  and  psychic  measures  have 
their  same  field  of  usefulness  in  this  neurosis  as  in  the  others. 

Gastrosuccorrhea,  or  Reichmann's  Disease.^ — In  this 
condition  gastric  juice  is  poured  out  in  great  excess  of  the 


394  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

digestive  needs,  so  that  not  only  is  there  an  extra  amount 
during  the  presence  of  food  in  the  stomach,  but  a  liberal 
amount  of  acid  fluid  can  be  found  at  nearly  any  time  in  the 
fasting  stomach. 

This  generally  occurs  as  an  acute  process,  running  a 
somewhat  uniform  course,  but  occasionally  chronic,  and 
interrupted  by  acute  exacerbations.  Though  gastrosuc- 
corrhea  has  heretofore  been  classed  as  a  neurosis,  it  now 
barely  holds  a  position  on  the  border-line  of  neuroses,  and 
some  there  are  who  claim  that  in  every  instance  there  is  a 
demonstrable  organic  cause  for  its  appearance.  Lockwood 
believes  that  it  is  the  result  of  a  combination  of  organic 
stenosis  and  pyloric  spasm. 

Diagnosis. — The  patient  complains  of  uneasy  sensations 
in  the  epigastrium,  with  fulness  and  distention,  especially 
if  a  full  meal  has  been  taken.  This  later  develops  into  a 
burning  or  boring  pain,  severe  and  depressing.  The  pain 
at  first  is  relieved  by  eating,  or  the  taking  of  alkalies,  but 
nothing  gives  ease  for  any  length  of  time  except  complete 
emptying  of  the  stomach  by  the  tube,  or  emesis.  This, 
however,  lasts  only  for  a  while,  for  with  the  pouring  out  of 
more  acid  the  suffering  returns. 

The  character  of  the  vomitus  is  generally  sufficient  to 
make  a  diagnosis.  This  vomitus  consists  almost  entirely  of 
fluid,  yellowish  or  greenish,  or  even  brownish  from  altered 
blood,  and  giving  a  strong  reaction  for  hydrochloric  acid. 
Food  may  be  in  the  vomitus,  if  a  meal  has  been  recently 
ingested,  but  usually  the  bulk  is  this  fluid.  The  liquid  vom- 
ited is  much  greater  in  amount  than  would  be  accounted 
for  by  fluids  ingested,  and  the  quantity  is  often  a  matter 
of  surprise  to  the  patient,  who  wonders  where  it  all  came 
from.  During  the  attack  there  is  exhaustion  and  loss  of 
weight,  and  thirst,  while  the  patient  finds  that  efforts  to 
quench  this  thirst  are  followed  by  gastric  unrest  and 
increased  vomiting.  Occasionally  severe  headache  super- 
venes, which  promptly  ceases  upon  emptying  the  stomach. 
The  bowels  are  usually  constipated,  the  urine  diminished 


TREATMENT    OF    GASTROSUCCORRHEA  395 

on  account  of  the  fluid  drain  in  the  stomach,  and  the  upper 
abdominal  wall  is  retracted.  Sometimes  the  acute  attack 
ends  as  abruptly  as  it  began,  but  this  must  not  be 
expected.  The  acute  manifestations  of  Reichmann's  dis- 
ease may  last  from  several  hours  to  three  or  four  days. 
Occasionally  the  disorder  merges  into  a  chronic  state, 
and  if  it  complicates  ulcer,  it  may  render  the  condition 
of  the  patient  most  serious. 

Treatment. — During  the  acute  attack  the  stomach  should 
as  far  as  possible  be  kept  empty,  no  food  being  allowed  for  a 
time,  and  occasional  large  draughts  of  water  given  to  pro- 
mote emesis,  or  lavage  with  an  alkaline  solution.  The 
stomach  contents  should  be  kept  as  alkaline  as  possible, 
and  alkaline  powders  or  liquids  should  be  administered 
freely.  Atropin  may  be  given  in  1/200  grain  doses  every 
two  or  three  hours  until  dryness  of  the  mouth  sets  in. 
For  the  severe  pain  morphin  may  be  given  hypoder- 
mically.  Hot  applications  over  the  epigastrium  may  be 
kept  up,  and  every  means  exerted  to  promote  quiet  and 
comfort. 

After  the  acute  symptoms  are  controlled,  and  feeding  be- 
gins, the  diet  is  practically  the  same  as  in  hyperchlorhydria. 

If  relief  is  not  obtained  promptly,  and  the  patient  seems 
to  be  approaching  exhaustion,  surgical  procedures  should 
be  considered. 

Alimentary  Hypersecretion. — This  is  less  severe  and  more 
chronic  than  Reichmann's  disease,  and  demands  treatment 
practically  similar  to  other  conditions  of  chronic  hyper- 
acidity, with  hydrotherapy,  change  of  scene,  and  if  possible, 
complete  rest. 

Achylia  Gastrica. — ^This  may  be  present  as  a  pure  neuro- 
sis. Instances  are  numerous  where  some  strong  emotion 
completely  inhibits  the  secretion  of  gastric  juice,  and  food 
may  be  later  vomited  in  an  unchanged  condition.  Achylia 
may  be  due  to  nervous  inhibition  of  secretion,  to  menstrual 
irritation,  or  to  fatigue.  There  are  some  neurotic  indi- 
viduals in  whom  this  condition  causes  but  little  inconveni- 


396  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

ence,  and  in  whom  at  times  the  gastric  secretion  may  be 
found  normal.  This  lack  of  juice,  when  it  appears  as  a 
simple  neurosis,  needs  therapeutic  measures  for  the  im- 
provement of  general  tone,  a  liberal  diet,  and  probably 
hydrotherapy. 

SECRETORY    NEUROSES    OF    THE    INTESTINES 

Nervous  Diarrhea. — This  may  be  a  pure  neurosis,  ac- 
companying fear  or  any  other  violent  emotion.  It  is  a 
matter  of  common  knowledge  among  soldiers  that  raw 
recruits  often  suffer  from  severe  nervous  diarrhea  the  first 
time  they  face  the  guns  of  the  enemy.  Increased  intestinal 
secretion  is  found  in  membranous  enteritis,  though  some 
do  not  consider  this  a  genuine  neurosis  of  secretion. 

Intestinal  Neurasthenia. — Combinations  of  the  intes- 
tinal neuroses  frequently  occur,  and  have  been  designated 
by  Rosenheim  as  intestinal  neurasthenia.  The  appetite 
may  be  good,  and  the  symptoms  usually  come  on  during 
intestinal  digestion,  or  about  two  or  three  hours  after 
meals. 

Diagnosis. — There  are  present  pressure,  tension,  and 
griping  in  the  abdomen,  occasionally  nausea,  and  at  times 
evacuations  of  the  bowels  accompanied  by  painful  sensa- 
tions in  the  abdomen  and  anus.  Palpitation  may  occur; 
sometimes  flashes  of  heat  and  cold.  Generally  the  patient 
feels  worse  when  quiet  and  recumbent,  than  when  walking 
about,  with  his  mind  diverted  from  his  trouble.  Consti- 
pation is  usually  present. 

The  discomfort  and  pain  do  not  seem  to  bear  any  rela- 
tion to  the  food  ingested,  and  at  times  full  meals  seem  to 
really  make  the  sufferer  feel  better.  Gastric  neuroses  are 
often  associated.  Anatomic  lesions  must  be  excluded,  and 
enteroptosis  must  be  accorded  an  important  bearing  on  the 
case,  if  present. 

Treatment. — The  general  nervous  and  physical  condition 
must  be  toned  up,  and  a  generous  but  unirritating  diet  is 


MUCOUS  COLIC  397 

indicated.  Regular  evacuations  of  the  bowels  are  desirable. 
Iron  and  arsenic  may  be  given  three  times  daily,  and  bro- 
mides in  the  intervals. 

Mucous  Colic  (Membranous  Enteritis). — This  malady  is 
known  by  many  names,  a  few  of  them  being  mucous  colitis, 
membranous  colitis,  pseudo-membranous  enteritis,  tubular 
diarrhea,  etc.  Nothnagel  first  suggested  the  name  '  'mucous 
colic,"  in  order  to  show  that  a  true  enteritis  need  not  exist. 

Though  this  distressing  trouble  is  in  the  main  a  neurosis, 
the  observer  must  be  watchful  for  association  organic  dis- 
ease. It  occurs  most  frequently  in  women  from  twenty  to 
forty,  seldom  late  in  life.  There  are  divergent  views  as  to 
its  etiology,  for  Mathieu  considers  it  a  hypersecretion  of 
mucus  in  patients  of  a  neuro-arthritic  type,  who  suffer  from 
enteroptosis,  intestinal  sand  being  present.  Von  Noorden 
ascribes  it  to  long-continued  constipation  in  nervous 
individuals,  while  Einhorn  places  it  among  the  neuroses, 
but  finds  that  it  is  associated  in  many  cases  with  Glenard's 
disease,  and  that  achylia  gastrica  is  present  in  many 
patients. 

Necropsies  are  rare  unless  death  results  from  intercurrent 
disease,  and  autopsies  have  demonstrated  that  no  inflamma- 
tory condition  existed  in  the  colon  that  would  account  for 
the  symptoms  during  life.  Nothnagel  contends  that  there 
are  two  classes  of  cases,  one  in  which  the  pure  "mucous 
colic"  with  hypersecretion  of  mucus  is  simply  a  neurosis; 
the  other  class  in  which  the  mucous  colic  is  engrafted  upon 
a  catarrhal  colitis,  leaving  anatomic  lesions. 

Diagnosis. — The  patient  may  pass  mucus  in  long,  thin 
bands,  ribbon-like  or  in  the  shape  of  a  tapeworm ;  they  may 
be  tubular  in  form,  making  a  cast  of  the  intestines;  they 
may  be  of  considerable  length,  and  the  mucus  may  be  in 
jelly-like  masses  or  shreds,  occasionally  streaked  with  blood. 
This  discharge  should  be  differentiated  from  tendons, 
membrane  of  oranges  or  other  adventitious  material  that 
may  escape  from  the  bowels.  The  color  of  the  mucus  is 
generally  grayish.     Microscopically,   the  membrane   con- 


398  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

sists  of  a  structureless  matrix,  its  chief  constituent  being 
mucus. 

The  patients  are  neurotic,  self-conscious,  and  usually 
quite  thin.  They  complain  of  constipation,  punctuated  by 
occasional  attacks  of  painful  diarrhea.  They  also  complain 
of  a  long  train  of  nervous  symptoms,  as  dizziness,  palpita- 
tion, gastric  distress,  etc.  On  palpation  of  the  abdomen, 
sensitive  points  will  generally  be  found.  The  patients  give 
a  history  of  severe  attacks  of  colic,  sudden  and  very  painful, 
with  aggravated  nervous  symptoms.  Presently  there  is 
passed  the  characteristic  mucus,  after  which  some  relief  is 
obtained,  though  there  may  be  a  number  of  paroxysms, 
followed  in  each  instance  by  the  passage  of  mucus  before 
permanent  ease  is  felt. 

Nothnagel  describes  two  types:  one,  in  which  mucous 
colic  is  engrafted  upon  a  chronic  catarrhal  colitis,  the  latter 
being  due  to  adhesions  from  appendicitis  or  peritonitis; 
the  other  class,  in  which  the  severe  cramp-like  pains  are 
absent,  the  patient  passing  the  mucus  very  often,  with  occa- 
sional tube-casts. 

In  a  large  proportion  of  these  patients  there  will  be  found 
a  gastroptosis,  enteroptosis,  or  a  general  dropping  of  the 
whole  abdominal  viscera,  with  consequent  kinks  and  torsion. 

Treatment. — These  patients  require  much  tact  and 
patience  in  management.  The  disease  is  generally  of  long 
duration,  but  with  proper  treatment  most  cases  can  be 
cured. 

During  the  attack  the  sufferer  should  be  put  to  bed  and 
hot  applications  freely  used  on  the  abdomen,  moist  heat  in 
the  form  of  hot  compresses  being  the  best. 

If  the  bowels  are  constipated,  copious  enemas  of  hot 
water,  or  hot  irrigations  will  be  of  service,  and  this  may  be 
followed  by  a  high  enema  of  warm  olive  or  cotten-seed  oil, 
which  should  be  retained  as  long  as  possible. 

Fluid  diet,  and  not  very  much  of  that,  should  be  given 
during  an  acute  attack,  though  plenty  of  water  may  be 
allowed. 


TREATMENT    OF    MUCOUS    COLIC  399 

A  hypodermic  of  morphin  is  sometimes  required,  though 
I  have  generally  been  able  to  control  the  suffering  with  hot 
applications  combined  with  gentle  carminatives  and  anti- 
spasmodics. The  frequent  administration  of  equal  parts  of 
the  aromatic  spirits  of  ammonia  and  elixir  of  the  valerianate 
of  ammonia  exerts  both  a  stimulant  and  sedative  effect. 

During  the  intervals  the  patient  should  be  liberally  fed, 
and,  if  the  physician  is  satisfied  that  no  ulcerated  or  de- 
cidedly inflamed  areas  exist  in  the  large  intestine,  the  diet 
should  contain  much  cellulose  and  residue,  as  recommended 
by  von  Noorden.  By  keeping  the  intestines  full  of  the 
insoluble  parts  of  the  diet,  it  is  contended,  and  I  think 
rightly,  that  mucus  cannot  find  lodgment  on  the  intestinal 
surface. 

Kemp  is  a  strong  believer  in  the  efficacy  of  the  Rose  belt, 
and  I  have  employed  it  in  several  cases  with  apparent  bene- 
fit. The  belt  is  specially  helpful  where  decided  enteroptosis 
exists. 

Intestinal  irrigations,  either  with  normal  saline  solution 
or  boric  acid  solution  are  helpful  to  keep  the  lower  bowel 
cleared  of  mucus.  No  irritating  medicaments,  as  nitrate 
of  silver,  nor  astringents,  as  tannin,  should  be  allowed  in 
these  irrigations.  The  injection  of  two  to  four  ounces  of 
cotton-seed  oil  in  the  rectum  at  night,  to  be  retained  till 
morning,  is  both  soothing  and  beneficial.  While  it  is 
extremely  desirable  that  constipation  should  not  exist, 
drastic  cathartics  are  never  indicated.  Liquid  albolene 
may  be  regularly  given  in  one  or  two  teaspoonful  doses 
before  meals,  this  preparation  seeming  to  lubricate  the  intes- 
tinal surface,  keeping  the  bowels  gently  open,  and  mitigat- 
ing the  symptoms  generally. 

Gentle  massage  over  the  abdomen  with  an  ointment 
composed  of  vaseline,  to  which  has  been  added  a  small 
amount  of  menthol  and  capsicum,  will  often  prove  comfort- 
ing to  the  patient. 

It  is  most  desirable  that  the  patient  be  kept  out  in  the 
open  air  between  attacks,  and  be  encouraged  to  engage  in 


400  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

such  exercise  that  will  strengthen  the  abdominal  muscles. 
An  abundance  of  water  should  be  insisted  upon. 

Surgical  Considerations. — Some  writers  have  recom- 
mended a  right  inguinal  colotomy  to  give  rest  to  the  colon 
in  certain  intractable  cases.  This,  however,  would  not 
relieve  the  ptosis.  In  severe  mucous  colitis,  complicated 
by  marked  splanchnoptosis,  shortening  the  suspensory 
ligaments  of  the  stomach  and  colon  has  been  advocated. 
Some  even  go  so  far  as  to  advise  a  tightening  of  the  abdomi- 
nal muscles  by  means  of  suturing,  so  as  to  relieve  the  mus- 
cular relaxation. 

I  should  hesitate  to  advise  surgery  in  this  condition,  and 
then  only  after  both  time  and  intelligent  care  had  been 
freely  expended.  Mucous  colitis,  when  markedly  a  neu- 
rotic expression,  does  not  lend  itself  kindly  to  surgery,  nor 
do  these  severe  measures  afford  permanent  relief. 

GENERAL    CONSIDERATIONS    IN    THERAPY  OF 
DIGESTIVE  NEUROSES 

These  considerations  embrace  every  phase  of  therapy, 
with  a  liberal  proportion  of  psychotherapy  at  all  times 
included. 

In  taking  charge  of  any  condition  thought  to  be  neurotic, 
the  patient  should  receive,  if  possible,  a  more  thorough  and 
painstaking  examination  than  he  has  ever  had.  This  serves 
the  double  purpose  of  affording  the  physician  a  courage 
born  of  knowledge,  and  of  inspiring  the  nervous  invalid 
with  a  sense  of  confidence.  This  examination  will  in  every 
instance  furnish  a  cue  by  which  a  preliminary  treatment 
may  be  inaugurated.  In  this  connection  let  me  emphasize 
the  fact  that  treatment  is  what  the  patient  desires,  and  as 
an  integral  part  of  this  treatment,  some  form  of  medication 
meets  both  an  intrinsic  and  psychic  need.  Should  there 
be  hyperchlorhydria,  an  oft-present  neurosis,  antacids 
sufficient  to  neutralize  the  excess  will  win  the  opening  skir- 
mish, and  increase  the  physician's  influence.     Hypoacidity 


GENERAL    CONSIDERATIONS  4OI 

calls  for  an  acid,  though  some  conditions  of  neurotic  achylia 
are  intolerant  of  any  form  of  acid.  Nearly  all  of  these 
patients  complain  of  flatulence  and  eructations,  and  will 
be  grateful  for  an  efficient  carminative,  though  the  physician 
must  remember  that  much  of  this  flatulence  is  due  to 
swallowed  atmospheric  air. 

On  point,  which  I  consider  almost  the  keynote  of  the 
treatment,  is  to  frequently  change  the  medicine  in  some 
way,  even  though  it  be  simply  a  change  of  appearance, 
every  few  days.  These  neurotic  alimentary  tracts  soon 
become  habituated  to  most  prescriptions,  and  unless  varied, 
the  latter  will  lose  their  effect  to  a  marked  extent.  I  have 
often  added  to  an  alkaline  powder  of  calcined  magnesia 
and  bismuth  a  little  powdered  charcoal  or  carmin  to  the 
increased  satisfaction  of  the  watchful  and  expectant  patient. 
The  active  and  indicated  base  of  the  prescription  may  re- 
main the  same,  so  long  as  the  adjuvants  are  frequently 
changed. 

The  question  of  gastric  lavage  is  somewhat  a  delicate 
one,  for  we  occasionally  encounter  highly  strung  people, 
who  derive  more  harm  than  good  from  this  procedure.  I 
might  say,  as  a  general  principle,  that  where  there  is  a 
marked  excess  of  stomach  mucus  or  delayed  evacuation  of 
the  gastric  contents,  an  alkaline  or  gently  antiseptic  lavage 
at  not  too  frequent  intervals  is  helpful ;  while  for  hypersen- 
sitiveness  of  the  gastric  mucosa  a  lavage  containing  40 
grains  of  nitrate  of  silver  to  the  pint,  and  followed  by  plain 
water  or  normal  salt  solution,  will  often  yield  gratifying 
results.     Routine  lavage  is  not  advisable. 

Faradic  electricity  has  proved  satisfactory  to  me,  though 
I  confess  the  belief  that  its  influence  is  mainly  psychic. 
As  to  massage,  vibratory  or  otherwise,  the  same  may  be 
said. 

For  indifferent  appetites,  the  bitter  stomachics,  condur- 

ango,  calumbo,  or  nux  vomica,  are  indicated,  with  tincture 

of  gentian  or  cinchona  as  a  base,  changing  them  often,  as  I 

have  previously  indicated.     Occasionally,  where  hypoacid- 

26 


402  NEUROSES,    MOTOR,    SENSORY,    AND    SECRETORY 

ity  exists,  the  3 -grain  doses  of  orexin  will  greatly  sharpen, 
the  desire  for  food. 

Hydrotherapy  is  useful  in  nearly  every  form  of  digestive 
neurosis,  aiding  as  it  does  the  emunctories,  cleansing  the 
bodily  Augean  Stables,  relaxing  the  nervous  tension,  and 
adding  its  quota  of  bodily  uplift. 

Change  of  environment,  or  even  occupation,  should  be 
recommended,  whenever  practicable;  in  fact,  there  are 
certain  of  these  cases  where  a  change,  the  more  radical  the 
better,  seems  the  only  method  by  which  the  discouraged 
invalid  may  obtain  a  start  on  the  road  to  recovery. 

The  whole  plan  of  therapy  is  based  upon  reinforcing  the 
weakened  digestive  functions,  wherever  situated;  pressing 
every  procedure  with  kindly  interest  and  sympathetic 
optimism;  keeping  the  patient's  mind  as  busy  as  possible, 
so  as  to  combat  introspection ;  dispelling  doubts,  and  fears ; 
furnishing  some  therapeutic  surprise,  if  possible,  at  every 
visit ;  encouraging  each  glimmering  ray  of  hope ;  providing 
ample  calories,  so  that  bodily  strength  may  promote  nerv- 
ous equilibrium;  and,  without  losing  sight  of  the  main 
issue,  taking  cognizance  of  the  countless  little  intercurrent 
and  irritating  ills  always  present. 

The  various  types  of  digestive  neuroses  produce  a  most 
unhappy  and  misunderstood  class  of  sufferers,  and  in  no 
division  of  therapeutic  endeavor  will  sincere,  thoughtful, 
and  persevering  efforts  on  the  part  of  the  medical  attendant 
yield  more  gratifying  results. 


CHAPTER  XVI 

THE  GASTRITES,  ACUTE  AND  CHRONIC 

Gastritis,  or  gastric  catarrh,  is  manifested  in  a  number  of 
ways,  depending  upon  the  causation,  the  condition  of  the 
stomach,  the  condition  of  the  patient,  and  the  course  of 
the  disease.  The  different  forms  of  gastritis  may  be  divided 
as  follows:  Simple  acute,  infectious,  toxic,  phlegmonous; 
and  chronic  forms,  being  chronic  with  excessive  acid,  or 
with  deficient  or  no  acid  (achylic  gastritis),  and  alcoholic 
gastritis. 

ACUTE  GASTRITIS 

This  is  a  most  frequent  affection,  no  age  or  condition  in 
life  being  exempt.  It  may  be  occasioned  by  errors  in  diet, 
mechanic  or  thermic  irritants,  foods  too  highly  seasoned, 
unripe  or  overripe  fruits,  poorly  cooked  or  spoiled  food, 
cold  or  carbonated  drinks,  excessive  use  of  alcohol,  or  any 
other  cause  that  lays  a  sudden  stress  upon  the  stomach. 
Some  individuals  seem  peculiarly  susceptible  to  acute 
inflammation  of  the  stomach,  while  others  are  able  to  eat 
with  seeming  impunity  articles  of  food  that  would  ordinarily 
set  up  a  most  acute  gastritis  in  average  persons. 

Toxic  gastritis  brought  on  by  spoiled  food  (a  phase  of 
cholera  nostras)  may  be  included,  and  also  infectious 
gastritis  caused  by  microorganisms  or  parasites  that  may 
find  their  way  into  the  stomach. 

Diagnosis. — The  patient  first  complains  of  loss  of  appe- 
tite, discomfort  in  the  epigastrium,  fulness  which  may  be 
relieved  by  belching,  and  occasional  nausea.  There  is 
seldom  a  rise  of  temperature.  In  the  more  severe  cases  the 
pains  are  acute,  there  is  headache,  nausea,  and  vomiting 

403 


404  THE    GASTRITES,    ACUTE   AND    CHRONIC 

which  is  prolonged,  excessive  and  painful,  the  vomitus 
consisting  first  of  food,  then  chiefly  of  mucus,  at  times 
streaked  with  blood  and  admixed  with  bile  which  regurgi- 
tates into  the  stomach  with  the  continuous  retching. 
There  may  be  chilly  sensations,  the  pulse  may  become 
rapid  and  thready,  the  tongue  coated  and  swollen.  Con- 
stipation or  diarrhea  may  be  present,  and  the  early  vomitus 
often  has  quite  a  disagreeable  odor.  Occasionally  a  duo- 
denitis with  jaundice  is  associated,  and  herpes  of  the  lips 
is  frequently  observed. 

Acute  gastritis  must  be  differentiated  from  biliary  colic, 
in  which  the  pain  radiates  to  the  right  side  or  shoulder, 
while  pain  over  the  gall-bladder  is  present ;  from  cholecys- 
titis with  or  without  calculi,  in  which  previous  history, 
tenderness  over  the  gall-bladder,  and  the  presence  of  a 
leukocytosis  must  be  taken  into  account ;  from  hyperchlor- 
hydria,  in  which  the  previous  history  must  be  considered; 
from  peritonitis,  in  which  there  is  muscular  rigidity,  marked 
abdominal  tenderness  and  distention;  and  from  nervous 
gastralgia,  in  which  the  vomitus  is  usually  very  acid  but 
containing  little  if  any  mucus,  the  neurotic  history  being 
suggestive.  Acute  gastritis  must  also  be  differentiated 
from  the  early  stages  of  typhoid  fever,  and  from  the  gastric 
crises  of  locomotor  ataxia. 

Treatment. — Patients  who  are  easily  upset  (with  "deli- 
cate stomachs")  should  sedulously  avoid  those  articles  of 
food  which  have  proved  irritating  in  the  past,  and  should 
empty  the  stomach  with  copious  draughts  of  warm  water 
upon  the  slightest  premonitions  of  trouble. 

The  symptoms  of  gastritis  having  developed,  the 
stomach  should  be  cleared,  as  well  as  the  intestinal  tract, 
and  the  patient  put  to  bed.  In  mild  cases,  rest  to  the  stom- 
ach and  quietude  to  the  body  will  suffice,  but  in  more  severe 
cases,  the  therapy  must  be  energetic. 

For  the  nausea  and  pyrosis  alkalies  should  be  freely 
administered,  either  in  the  dry  form  as  bismuth  or  calcined 
magnesia,  or  milk  of  magnesia  or  bismuth  with  some  car- 


TREATMENT  OF  ACUTE  GASTRITIS  405 

minative  flavoring  agent.  The  presence  of  nausea  requires 
external  counter-irritation.  For  nausea  and  acidity  the 
following  prescription  has  often  proved  helpful  in  my  hands : 

I^.     Spts.  amygdalas  amare 3ii- 

Resorcinolis gr.  x. 

Lac-magnesice q.s.  ad.  gii. 

SiG.- — One  teaspoonful  every  two  or  three  hours. 

Among  other  antiemetics,  which  may  be  used  from  time 
to  time,  are  oxalate  of  cerium,  i -minim  doses  of  Fowler's 
solution  or  tincture  of  iodin,  or  small  pellets  of  ice  given 
sparingly.  The  use  of  cocain  or  carbolic  acid  is  not  satis- 
factory. Occasionally  a  hypodermic  of  morphin  may  be 
required  to  control  the  extreme  pain  and  nausea,  but  it  will 
be  generally  found  that  the  secondary  effects  are  not  good. 

Occasionally  the  patient  will  prefer  an  ice-bag  over 
the  epigastrium,  but  the  majority  are  more  comfortable 
under  the  application  of  heat,  which  should  be  employed 
perseveringly.  ' 

Lavage  is  occasionally  of  service  when  there  is  distressing 
nausea  with  ineffectual  attempts  to  expel  the  glairy  mucus, 
but,  unless  the  lavage  can  be  administered  by  an  expert, 
it  had  best  be  omitted. 

Diet. — Entire  abstinence  from  food  for  twenty-four 
hours  in  ordinary  cases,  and  for  two  or  three  days  in  severe 
ones,  is  advisable.  Rectal  feeding  in  acute  gastritis  is  not 
satisfactory,  as  a  rule.  Einhorn  has  used  duodenal  alimen- 
tation in  several  cases  with  good  results. 

After  the  symptoms  begin  to  subside,  very  light  nourish- 
ment may  be  given,  though  caution  must  be  observed. 
Egg-albumen,  ice-cold;  barley-water,  alone  or  with  a  little 
milk,  or  rice  gruel  with  milk,  are  eligible  foods  to  begin 
with.  Later  there  may  be  cautiously  added  soft-boiled 
eggs,  scraped  beef,  bouillon,  zwieback,  broths,  and  a  gradual 
resumption  of  the  full  diet.  The  patient,  however,  should 
be  careful  for  quite  a  while,  as  dietetic  indiscretions  will  be 
liable  to  result  in  other  acute  attacks. 


4o6  THE    GASTRITES,    ACUTE    AND    CHRONIC 

ACUTE  INFECTIOUS  GASTRITIS 

This  form  of  acute  gastritis  is  generally  precipitated  by 
microorganisms  introduced  into  the  stomach  with  decom- 
posed food,  especially  meat  or  fruit,  bad  milk,  or  infected 
water. 

Diagnosis. — ^This  disorder  presents  much  the  same  pic- 
ture as  simple  acute  gastritis,  plus  excessive  prostration. 
The  temperature,  which  is  normal  or  even  sub-normal  in 
mild  gastritis,  is  considerably  elevated  in  this  form. 

This  condition  does  not  necessarily  follow  dietetic  errors, 
but  is  generally  the  result  of  pure  infection.  With  the  fever 
are  noted  violent  headache,  thirst,  quick  pulse,  and  a 
marked  diminution  of  gastric  juice.  The  acute  symptoms 
may  merge  into  a  semi-chronic  character,  keeping  the 'pa- 
tient ill  and  uncomfortable  for  one  or  more  weeks. 

This  is  the  form  of  gastritis  sometimes  rightly,  and  some- 
times wrongly,  denominated  "ptomaine  poisoning,"  and 
questions  involved  often  possess  a  medico-legal  significance. 

Occasionally  death  results  from  infectious  gastritis, 
but  usually,  after  a  brief  but  stormy  illness,  the  patient 
recovers. 

Treatment. — The  treatment  is  based  upon  the  same 
principles  as  obtain  in  simple  acute  gastritis,  except  it  is 
advisable  to  thoroughly  empty  and  cleanse  the  stomach  by 
an  alkaline  antiseptic  lavage.  A  solution  of  boric  acid, 
or  a  1 :  3000  permanganate  of  potash  in  normal  salt  solution, 
or  a  1 :  20  of  the  alkaline  antiseptic  liquid  (National  Formu- 
lary) will  be  suitable. 

No  food  should  be  allowed  in  the  stomach  for  several 
days,  though  it  may  be  necessary  to  administer  diffusible 
stimulants  in  small  quantities.  Wine  or  brandy  are  some- 
times advisable  in  weak  or  debilitated  subjects. 

The  physician  should  be  cautious  in  resuming  stomach 
feeding,  and  should  be  specially  cautious  in  passing  from 
liquid  to  solid  food;  and,  should  nausea  or  vomiting  seem 
imminent,  should  resort  to  nutrient  enemas. 


TOXIC    GASTRITIS  407 

Drug  Therapy. — This  comprises  the  remedies  employed 
in  the  milder  forms  of  acute  gastritis,  with  the  addition 
generally  of  small  doses  of  dilute  hydrochloric  acid,  well 
diluted.  A  most  useful  combination  to  quiet  the  stomach 
and  abate  the  nausea  consists  of  the  following: 

I^.     Hydrarg.  chlor.  mitis, 

Phenolphthalein aa  gr.  i. 

Sacch.  lactis gr-  v. 

Ft.  chartulae  No.  10. 
SiG. — One  powder  dry  on  the  tongue  every  hour  until  five 

are  taken. 

The  extreme  thirst  may  be  quenched  by  pellets  of  ice  or 
high  saline  enemas. 

TOXIC  GASTRITIS 

This  most  intense  form  of  inflammation  of  the  stomach  is 
caused  by  the  swallowing  of  concentrated  mineral  acids, 
strong  alkalies,  or  poisons,  such  as  phosphorus  or  arsenic. 
Among  the  extremely  irritant  acids  are  nitric,  sulphuric, 
hydrochloric,  oxalic,  and  carbolic;  the  caustic  alkalies, 
including  caustic  potash  or  soda,  soap  lees,  and  strong 
ammonia ;  and  other  irritants  as  alcohol,  potassium  cyanid, 
corrosive  sublimate,  and  potassium  chlorate.  The  effects 
of  all  these  poisons  are  more  intense  when  taken  on  an 
empty  stomach. 

When  such  agents  are  swallowed,  the  acids  and  alkalies 
destroy  the  integrity  of  the  parts  with  which  they  come  in 
contact,  causing  various  degrees  of  sloughing  of  the  mucosa 
and  sub-mucosa,  sometimes  followed  by  penetration  of  the 
stomach  wall  and  perforative  peritonitis. 

Diagnosis. — The  symptoms  are  of  a  fulminating  charac- 
ter, as  seen  in  acute  intoxication,  modified  by  the  nature  of 
the  poison  ingested.  The  sudden  appearance  of  violent 
gastric  symptoms  in  a  perfectly  healthy  individual  should 
excite  suspicion.  Inspection  of  the  lips,  mouth,  and  tongue 
will  show  the  effects  of  corrosive  poison,  if  such  has  been 
taken,  and  examination  of  the  vomitus  and  odor  of  the 


408  THE    GASTRITES,    ACUTE   AND    CHRONIC 

breath  may  afford  additional  information.  Sometimes  it  is 
possible  to  find  the  receptacle  or  bottle  from  which  the  poi- 
son was  taken,  or  the  patient  may  give  the  desired  history. 

Treatment.- — ^There  are  certain  general  principles  in  the 
treatment  of  toxic  gastritis:  first,  administer  fluid  to  dilute 
the  posion,  and  at  the  same  time  give  an  antidote ;  empty 
the  stomach  as  rapidly  as  can  be  done  by  lavage;  if  the 
poison  is  corrosive,  administer  demulcents;  stimulate  the 
patient,  if  the  vital  powers  are  weak,  and,  if  any  of  the 
poison  has  passed  beyond  the  stomach,  give  a  cathartic. 
Lavage  by  siphonage  or,  that  failing,  by  aspiration,  is  indi- 
cated in  practically  all  cases  of  poisoning,  and  any  fancied 
danger  of  puncturing  the  stomach  by  the  tube  is  immeasur- 
ably overbalanced  by  the  potential  benefits  of  the  lavage. 
Should  no  stomach  tube  be  at  hand,  one  can  be  improvised 
from  a  fountain  syringe  by  removing  the  tip  and  clip, 
rounding  the  edges  of  the  end  of  the  rubber  tube,  and  using 
a  kitchen  funnel. 

Apomorphin — one-tenth  of  a  grain  hypodermatically,  or 
zinc  sulphate  or  alum  in  warm  water  may  be  given  to  pro- 
mote emesis.  Among  useful  demulcents,  which  are  gener- 
ally at  hand,  are  whites  of  raw  eggs,  milk,  olive  or  cot- 
ton-seed oil,  flour  boiled  with  water,  starch-  or  gum-arabic- 
water. 

The  later  treatment,  after  the  toxic  symptoms  are  con- 
trolled, are  similar  to  other  forms  of  acute  gastritis. 

PHLEGMONOUS  GASTRITIS 

This  rare  condition  is  also  called  acute  interstitial  gas- 
tritis, and  is  used  to  characterize  those  cases  of  inflamma- 
tion of  the  stomach  in  which  the  gastric  submucosa,  and  to 
a  lesser  extent,  the  mucous  and  serous  coats  are  uniformly  or 
f ocally  filled  with  pus  (Lockwood) .  Up  to  the  present  only 
about  one  hundred  cases  have  been  reported.  Men  are 
more  frequently  affected  than  women  in  the  proportion  of 
about  three  to  one.     Among  the  reported  cases,  about  one- 


PHLEGMONOUS    GASTRITIS 


409 


half  have  occurred  among  day  laborers,  who  were  addicted 
to  alcoholic  and  dietetic  excesses.  Alcohol  is  thought  to  be 
an  etiologic  factor,  though  a  goodly  proportion  of  the  cases 
has  been  among  non-alcohoHcs.  The  disease  is  not  hmited 
to  any  particular  age.  The  primary  cause  is  always  micro- 
bic,  especially  the  streptococcus,  which  probably  enters 
through  some  solution  of  continuity  in  the  mucous  mem- 
brane; or  secondary,  due  to  pyemia,  puerperal  infection  or 
the  exanthemata. 

Diagnosis. — -The  diagnosis  is  exceedingly  difficult  during 
life,  but  few,  if  any,  having  been  correctly  made  in  advance 
of  necropsy.  The  patient  presents  all  the  aspects  of  an 
acute  infection,  with  delirium  and  coma  preceding  death. 
The  blood  examination  shows  leucocytocytosis  with  in- 
crease in  the  polynuclears.  There  is  muscular  rigidity  in 
the  upper  portion  of  the  abdomen,  due  to  peritoneal  irri- 
tation even  before  perforation  takes  place.  When  this 
occurs  there  are  the  usual  manifestations  of  general  periton- 
itis. In  the  cases  of  circumscribed  abscess  the  tenderness 
is  more  locahzed,  the  symptoms  not  so  fulminating,  and  the 
duration  more  prolonged.  The  duration  may  be  from 
three  or  four  days  to  several  weeks. 

The  high  temperature,  chills,  and  early  muscular  rigidity, 
with  exquisitely  tender  epigastrium  point  to  an  acute 
suppurative  process  of  the  stomach.  Differentiation  of 
locahzed  gastric  phlegmon  from  a  locahzed  peritoneal  ab- 
scess foUowing  perforation  of  the  stomach  wall  by  ulcer  or 
cancer  is  practically  impossible.  Abscess  of  the  liver,  acute 
pancreatitis,  and  acute  cholecystitis  can  be  differentiated 
by  their  history  and  other  significant  diagnostic  points. 

The  prognosis  is  very  unfavorable,  the  mortahty  rate 
being  about  95  to  98  per  cent.  All  cases  of  recovery 
reported  have  been  of  the  circumscribed  form. 

Treatment. — Reahzing  the  difficulties  in  diagnosis,  and 
the  unfavorable  terminations  of  this  disease,  treatment 
holds  out  but  little  encouragement.  Laparotomy  may  be 
resorted  to  in  the  vague  hope  of  affording  some  rehef. 


4IO  THE    GASTRITE5.    ACUTE    AXD    CHROXIC 

Should  this  not  be  attempted,  an  ice-bag  may  be  kept  over 
the  epigastrium,  energetic  rectal  feeding  ma3^  be  used,  enter- 
ocl^^sis  may  be  administered  to  relieve  tympanites,  injec- 
tions of  the  mixed  vaccines  resorted  to,  and  the  pain  assua.ged 
with  opiates.  By  using  a  supportive  and  stimulating 
treatment  with  vigor,  the  patient  has  a  slender  chance  for 
recover}'. 

CHROXIC  CATARRHAL  GASTRITIS 

Up  to  the  time  that  more  exact  methods  of  examination 
came  into  vogue  the  diagnoses  of  chronic  gastritis,  chronic 
catarrh  of  the  stomach,  and  chronic  dyspepsia  were  made 
in  those  cases  of  digestive  disturbance  characterized  by 
long-continued  nausea  and  indigestion,  unless  the  symp- 
toms of  tdcer  or  cancer  stood  out  predominantly. 

Since  the  refinements  of  diagnosis  have  enabled  gastric 
diseases  to  be  more  intelligently  discriminated,  this  diag- 
nosis is  not  made  so  frequently  as  formerh',  though  even 
now  about  S  or  lo  per  cent,  of  chronic  indigestions  may  be 
placed  in  this  class. 

This  disease  occurs  more  frequently  in  men  than  in 
women,  and  the  same  irritating  causes  that  produce  acute 
gastritis  can  produce  the  chronic  t^-pe  when  exerted  for  a 
long  period  of  time;  such  as  hasty  eating  with  imperfect 
mastication,  gastronomic  excesses,  highly  spiced  foods  and 
condiments,  overindulgence  in  tea,  coffee  or  alcohol,  ex- 
cessive use  of  tobacco,  especially  chewing  strong,  black 
tobacco,  habitual  use  of  certain  drugs,  and  a  septic  condi- 
tion of  the  teeth  as  pyorrhea  alveolaris,  in  which  constant 
swallowing  of  pus  and  other  products  of  decomposition 
sets  up  inflammation.  Though  smoking  is  ascribed  as  a 
cause  by  some  writers,  I  have  never  seen  a  case  of  chronic 
gastritis  that  could  be  honestty  traced  to  that  habit.  (Let 
this  not  be  considered  a  defense  of  smoking,  for  many  forms 
of  neurotic  indigestion  or  even  atony  ma^'  follow  in  the  wake 
of  excessive  indulgence  in  this  use  of  tobacco.)  Probably 
the  commonest  cause  is  found  in  the  abuse  of  alcoholic 


CHRONIC    CATARRHAL    GASTRITIS  411 

drinks,  though  some  stomachs  seem  to  bear  without  injury 
quantities  of  alcohol  that  would  acutely  inflame  others. 
I  have  seen  a  few  individuals  who  suffered  from  chronic 
gastritis  for  two  or  more  weeks  after  the  ingestion  of  less 
than  4  ounces  of  rye  whiskey. 

Acute  gastritis  does  not  generally  merge  into  the  chronic 
form,  except  where  there  are  a  number  of  recurrences  at 
short  intervals  from  similar  causative  factors.  It  may  be 
secondary  to  acute  infectious  diseases,  as  typhoid  fever, 
and  is  frequently  associated  with  cancer  of  the  stomach. 
It  may  be  secondary  to  cirrhosis  of  the  liver,  pulmonary 
or  cardiac  disease,  and  chronic  nephritis  and  syphilis. 

There  are  several  forms  of  chronic  gastritis,  as  follows : 

The  form  in  which  there  is  excess  acid — acid  gastritis, 
hypersthenic  gastritis,  or  acid  catarrh  of  the  stomach. 

The  form  in  which,  while  there  is  chronic  catarrh,  there  is 
practically  normal  acidity. 

The  form  in  which  there  is  a  diminution  or  absence  of 
acid,  denominated  asthenic  gastritis,  sub-acid  gastritis, 
achylic  gastritis  or  atrophic  gastritis. 

To  this  may  be  added  a  rather  specific  form — alcoholic 
gastritis. 

Symptoms  of  Chronic  Catarrhal  Gastritis. — ^These  are 
much  like  those  of  other  gastric  disturbance.  The  disease, 
as  a  rule,  develops  slowly,  changing  in  its  aspect  from  time 
to  time.  The  appetite  is  variable,  sometimes  being  quite 
good,  or  even  ravenous,  then  for  a  time  the  patient  may 
have  absolutely  none.  A  disagreeable  taste  in  the  mouth 
is  often  mentioned,  there  is  thirst  and  dryness  of  the  mouth 
with  frequent  eructations  of  ill-smelling  gas  containing 
occasional  food  remnants.  Pressure  and  fulness  after 
eating  are  complained  of,  with  palpitation  of  the  heart 
during  the  digestion  of  meals.  For  a  while  the  eructations 
seem,  to  relieve  most  of  the  distressing  symptoms,  but  as 
the  disease  progresses,  there  is  almost  constant  uneasiness 
in  the  epigastric  region  during  waking  hours.  The  sleep, 
however,  is  troubled,  and  the  patient  often  awakes  with 


412  THE    GASTRITES,    ACUTE   AND    CHRONIC 

headache,  followed  by  vertigo  on  arising.  The  bowels  are 
usually  constipated,  with  perhaps  an  occasional  attack  of 
diarrhea. 

When  vomiting  occiirs,  it  is  usually  in  the  morning,  and 
consists  chiefly  of  slimy  mucus,  with  occasional  remnants 
of  the  previously  ingested  food.  The  tongue  is  sometimes 
covered  with  a  thick  gray  fur,  though  this  is  by  no  means 
characteristic.  Odor  of  the  breath  is  offensive,  especially 
when  there  is  atony  of  the  stomach  with  fermentation,  or 
the  teeth  are  in  poor  condition. 

Nearly  all  of  these  patients  are  low  spirited  and  pessi- 
mistic. It  appears  that  the  complex  of  symptoms  em- 
braced in  chronic  catarrhal  gastritis  exercises  a  peculiarly 
depressing  effect  on  the  mentality,  and  seldom  have  I  seen 
any  individual  suffering  from  this  disorder,  who  did  not 
feel  his  spirits  dampened  and  his  mental  horizon  beclouded. 

The  patient's  appearance  may  be  quite  good,  and  he  may 
preserve  his  weight  remarkably  well.  In  severe  cases  he 
looks  bad,  shows  black  rings  under  his  eyes  and  chills 
easily.  Where  the  anorexia  is  prolonged  much  weight 
may  be  lost,  and  an  extremely  emaciated  state  may 
supervene. 

Upon  physical  examina.tion  the  epigastrium  may  appear 
bloated.  Tympanites  is  sometimes  present,  but  the  stom- 
ach is  usually  in  the  normal  position.  The  gastric  region 
is  sensitive  to  pressure,  with  rather  diffuse  tenderness. 
There  is  seldom  any  real  sense  of  resistance  or  rigidity  there. 

A  splashing  sound  that  is  found  when  the  stomach  should 
be  empty  signifies  atony.  When  the  stomach  contains 
food,  liquid,  or  gas,  this  splashing  sound  possesses  little 
diagnostic  importance. 

The  urine  is  generally  scanty,  with  increased  specific 
gravity.  It  is  frequently  loaded  with  phosphates  and 
urates. 

Diagnosis. — The  diagnosis  of  chronic  catarrh  of  the  stom- 
ach cannot  be  positively  and  intelligently  made  without 
the  employment  of  the  stomach-tube.     By  gastric  analysis 


CHRONIC    CATARRHAL    GASTRITIS  413 

many  suspected  cases  prove  to  have  normal  gastric  con- 
tents, and  are  to  be  considered  neuroses;  while  in  other 
cases,  evident  gastric  catarrh  is  discovered  when  some  other 
condition  was  thought  more  probable. 

Lockwood  insists  that : 

(i)  Gastric  analyses  should  always  be  made  in  every 
case  of  dyspepsia,  no  matter  whether  these  symptoms  be 
apparently  gastric  or  intestinal,  unless  passage  of  the  tube 
is  contraindicated. 

(2)  Gastric  analyses  should  be  made  in  every  case  of 
chronic  diarrhea  that  is  not  due  to  evident  disease  of  the 
colon  or  rectum. 

(3)  Gastric  analyses  should  always  be  made  in  all  cases 
of  intestinal  toxemia,  of  recurring  headache  of  toxic  origin, 
and  in  patients  who  complain  of  the  symptom-complex 
which  is  spoken  of  by  the  laity  as  "biliousness." 

(4)  Gastric  analyses  should  be  made  in  all  cases  of  anemia 
and  general  physical  wretchedness  without  known  cause  and 
which  are  rebellious  to  treatment. 

The  presence  of  gastric  mucus  in  excessive  quantities  in 
the  stomach  contents  is  the  chief  diagnostic  point  in  chronic 
catarrhal  gastritis. 

My  usual  procedure  is  as  follows:  One  hour  after  an 
Ewald-Boas  test-meal  has  been  taken  (two  slices  of  bread 
without  butter  and  a  glass  and  a  half  of  water),  a  suffi- 
ciency of  the  stomach  contents  are  aspirated  for  an  exam- 
ination. In  chronic  catarrhal  gastritis  these  conditions  are 
usually  found  present:  the  total  acidity  is  often  dimin- 
ished; free  hydrochloric  acid  is  small  in  amount,  or  absent; 
pepsin  and  rennin  are  present  but  diminished ;  erythrodex- 
trin  present  in  small  quantities;  achroodextrin  and  sugar 
abundant.  Should  the  gastric  contents  well  up  into  the 
tube  in  great  quantity,  hypersecretion  may  be  suspected. 

The  particles  of  bread  are  not  as  fine  as  normally,  but 
larger  and  coarser.  Mucus  is  intimately  mixed  with  food 
remnants  and  is  adherent  to  the  larger  particles.  Upon 
passing  a  wire  up  through  the  contents,  thick,  tenacious 


414  THE    GASTRITES,    ACUTE    AND    CHRONIC 

ropes  of  glairy  mucus  hang  to  it,  presenting  a  characteristic 
appearance.  Should  there  appear  but  little  mucus  when 
the  symptoms  would  indicate  its  presence,  the  patient 
should  be  seen  the  following  morning  with  an  empty  stom- 
ach, and  lavage  performed,  in  which  event,  the  mucus  will 
be  easily  discovered  in  the  wash-water. 

Microscopically. — Mucus,  round  cells  and  epithelial 
cells  are  found  to  be  present.  In  doubtful  cases  the  micro- 
scope may  enable  the  physician  to  differentiate  the  types  of 
mucus.  If  squamous  epithelium  is  mixed  with  it,  this 
probably  comes  from  the  mouth  or  pharynx;  if  pigmented 
alveolar  epithelia,  probably  from  the  air  passages.  Col- 
umnar epithelia  mixed  with  mucus  shows  its  gastric  origin. 

Chemical  Findings. — With  acid  gastritis  we  find  the  free 
hydrochloric  and  total  acidity  somewhat  or  greatly  in- 
creased, though  this  reaction  bears  but  little  comparative 
relation  to  the  amount  of  mucus  present.  The  observant 
physician  may  find  cases  of  marked  catarrhal  gastritis  in 
which  the  acidity  remains  practically  normal,  notwithstand- 
ing gastric  disturbance,  anorexia,  and  malaise. 

In  sub-acid  gastritis  there  may  appear  all  gradations 
from  a  slightly  reduced  acidity  to  a  complete  absence  of 
gastric  juice,  or  achylic  gastritis. 

Einhorn  has  carefully  examined  the  washings  of  many 
cases,  finding  small  shreds  of  the  mucosa  present,  which  he 
believes  to  be  due  to  erosions. 

Motility. — This  is  generally  good  in  acid  cases,  in  fact 
the  tendency  is  toward  an  increased  evacuation  of  the 
stomach.  Should  atony  or  dilatation  be  present,  there  is 
naturally  motor  insufficiency,  and,  in  the  absence  of  acid, 
fermentation. 

Absorption. — While  physiologic  absorption  in  the  stom- 
ach is  but  slight,  even  that  small  amount  is  interfered  with 
when  the  mucosa  is  coated  with  thick,  glairy  mucus. 

Course. — ^The  tendency  of  all  chronic  gastrites  is  toward  a 
long  duration,  and,  like  some  cases  of  post-nasal  catarrh, 
may  extend  over  many  years  without  incapacitating  the 


ACHYLIA    GASTRIC  A  415 

patient  for  the  ordinary  duties  of  life.  Even  where  there 
seems  to  be  decided  improvement,  relapses  are  frequent,  and 
no  one  can  be  considered  permanently  cured  until  many 
months  have  elapsed  without  gastric  disturbance. 

Differential  Diagnosis. — The  following  differential  points 
are  succinctly  stated  by  Kemp : 

Chronic  Gastritis. — ^No  severe  pain;  no  circumscribed 
spot  painful  to  pressure;  no  hematemesis;  no  cachexia; 
no  marked  emaciation,  except  in  severe  cases  of  long  dura- 
tion; free  hydrochloric  diminished  or  absent ;  gastric  mucus 
present;  slow  course. 

Ulcer  of  the  Stomach. — Hyperchlorhydria  present,  but 
not  invariably  so;  severe  pain  in  the  epigastrium  with 
intervals  free  from  pain  when  stomach  is  empty;  local 
tenderness  which  is  circumscribed;  dorsal  pain;  hemate- 
mesis, or  occult  blood  in  the  stool  or  gastric  contents; 
microscopic  pus ;  no  mucus;  patient  has  appearance  of  suf- 
fering; no  true  cachexia. 

Cancer  of  the  Stomach. — Age  usually  over  forty-five; 
rapid  course;  free  hydrochloric  acid  usually  markedly 
diminished  or  absent;  lactic  acid  present;  mucus  some- 
times present;  pain  generally  continuous,  but  not  so  acute 
as  in  ulcer;  Boas-Oppler  bacillus;  cachexia;  tumor  on 
physical  examination;  small  amount  of  visible  or  occult 
blood  present  in  gastric  contents;  microscopic  pus;  hema- 
temesis much  less  than  ulcer ;  foul  odor  to  vomitus  at  times 
present. 

Achylia  Gastrica. — Slow  course;  scarcely  any  gastric 
juice;  acidity  very  low  or  entirely  absent;  absence  of 
pepsin  and  rennin ;  usually  no  mucus  nor  lactic  acid. 

These  differential  considerations  apply  to  typic  cases, 
and  the  observer  must  be  on  the  qui  vive  for  various  grada- 
tions and  modifications  of  these  clinical  pictures. 

ACHYLIA  GASTRICA 

This  term  introduced  into  medical  literature  by  Einhorn 
denotes    absence    of    gastric    secretion.     Many    stomachs 


41 6  THE    GASTRITES,    ACUTE   AND    CHRONIC 

secrete  little  or  no  hydrochloric  acid,  and  still  seem  to  per- 
form their  functions  with  a  fair  amount  of  efficiency.  A 
test,  however,  will  disclose  the  presence  of  the  ferments  in 
dependable  quantities.  Achylia  may  accompany  cancer, 
severe  anemia,  or  result  from  long-continued  catarrhal 
gastritis.  Einhorn  claims  that  it  may  occur  as  a  purely 
functional  disturbance  wholly  apart  from  primary  organic 
disease  of  the  stomach  or  other  organs. 

Achylia  gastrica  as  a  pathologic  entity  should  not  be 
confounded  with  achylia  resulting  from  organic  or  other 
severe  disease  of  the  stomach.  It  is  undoubtedly  true  that 
some  individuals  possess  stomachs  with  absolutely  no 
functionating  power,  and  still  by  the  apparent  compensa- 
tory power  of  the  pancreatic  and  other  intestinal  juices, 
these  people  live  and  labor  in  seeming  health  and 
comfort. 

Diagnosis. — The  clinical  symptoms  of  this  condition  are 
much  the  same  as  in  chronic  catarrhal  gastritis,  being 
anorexia,  slight  or  severe  nausea,  eructations,  and  ill-defined 
sensations  of  discomfort  in  the  gastric  region.  Sometimes 
the  patient  complains  of  no  illness,  and  the  achylia  is  dis- 
covered by  accident.  There  is  in  this  city  an  active  physi- 
cian, a  man  who  accomplishes  a  wonderful  amount  of  useful 
work,  whose  stomach  has  not  secreted  any  juice  in  five  or 
more  years.  While  he  is  limited  in  his  diet  to  some  extent, 
he  enjoys  average  health,  and  displays  a  remarkable  amount 
of  energy. 

There  is  often  an  acceleration  of  the  motility  of  the  stom- 
ach, caused  no  doubt  by  the  lack  of  the  stimulating  influ- 
ence of  the  acid  chyme  against  the  pylorus.  These  patients 
are  dependent  on  high  functional  activity  of  the  small 
intestine,  and,  should  this  fall  below  par,  the  result  would 
be  a  probable  diarrhea  (gastrogenic  diarrhea) ,  which  greatly 
would  debilitate  the  patient. 

There  might  be  mentioned  in  this  connection  the  form  of 
achylia  which  accompanies  grave  cases  of  anemia,  perni- 
cious anemia,  and  the  anemia  due  to  the  Bothriocephalus 


TREATMENT    OF    CHRONIC    GASTRITIS  417 

latus,  though  the  relation  between  achyha  and  these  patho- 
logic states  is  not  understood. 

TREATMENT  OF  CHRONIC  GASTRITIS 

The  main  features  of  treatment  will  be  discussed,  attempt 
ing  to  note  the  various  modifications  incident  to  the  pres- 
ence of  increased,  diminished,  or  deficient  acid  and  other 
gastric  juices. 

Treatment  may  be  divided  into:  (i)  Prophylaxis.  (2) 
Hygiene.  (3)  Local  treatment  of  the  stomach.  (4)  Diet. 
(5)   Medication,  and  perhaps  (6)  Mineral  springs. 

In  border-line  cases  the  general  principles  applying  to 
hyperchlorhydria  may  be  applied  with  safety  until  a  defi- 
nite diagnosis  is  arrived  at. 

Prophylaxis. — This  is  probably  the  most  important,  and 
consists  in  the  correction  of  all  causes  contributory  or 
aggravating,  that  may  be  apparent  in  connection  with  the 
gastric  catarrh.  Dietetic  errors  must  be  inquired  into, 
and  both  regularity  and  uniformity  of  the  meals  enjoined. 
Some  patients  claim  that  their  dietetic  and  other  habits  are 
already  correct,  but  if  the  physician  will  have  them  keep 
for  several  days  a  written  memorandum  of  every  article 
eaten  and  every  daily  act,  there  will  generally  be  found 
some  information  which  can  be  acted  upon  with  advantage. 
Deliberate  eating,  adequate  mastication,  and  thorough 
insalivation  should  be  insisted  upon,  and  it  is  well  that  the 
physician  should  personally  see  to  it  that  the  teeth  are  in 
such  condition  so  that  good  mastication  may  be  performed 
without  discomfort.  Should  Rigg's  disease,  or  pyorrhea 
alveolaris,  be  present,  the  physician  should  be  slow  to  prom- 
ise much  improvement  until  this  very  important  contribu- 
tory irritation  is  abated.  Catarrhal  states  of  the  post- 
nasal cavities  should  also  be  investigated  and  cared  for,  and 
tonsillar  or  pharyngeal  disease  should  receive  appropriate 
attention.  Pathologic  conditions  of  the  tonsils  with  their 
potency  for  evil  are  just  now  beginning  to  be  accepted  at 
their  true  value. 
27 


41 8  THE    GASTRITES,    ACUTE   AND    CHRONIC 

Cardiac  disease,  especially  with  failing  compensation, 
should  be  properly  treated;  likewise  diseases  of  the  liver 
and  kidneys,  so  as  to  lessen  the  liability  to  secondary 
gastritis. 

Moderate  smoking  is  not  injurious  as  a  general  rule,  but 
chewing  tobacco,  especially  black  tobacco,  or  that  which  is 
sweetened,  is  quite  harmful,  and  should  be  prohibited. 
Should  the  "cathartic  habit"  be  indulged  in  to  an  inordi- 
nate extent,  this  too,  should  be  regulated,  and  evacuations 
of  the  bowels  be  accomplished  by  harmless  means. 

Hygiene. — A  favorable  mental  attitude  should  be  sought 
during  meal-times,  so  as  to  promote  the  benign  and  helpful 
influences  of  the  psychic  aids  to  digestion.  If  practicable, 
a  rest,  or  a  brief  season  of  bodily  and  mental  quietude 
should  be  enjoyed  directly  after  meals,  and  the  body  should 
be  strengthened  by  properly  directed  exercise.  The  venti- 
lation of  both  the  living  and  sleeping  rooms  is  worth  investi- 
gating, and,  when  convenient,  a  change  of  climate,  environ- 
ment, or  even  occupation  may  be  of  assistance  in  the 
treatment. 

Local  Measures  of  Treatment.^ — -The  removal  of  excessive 
mucus  and  the  soothing  of  the  irritated  gastric  mucosa  are 
of  equal  importance. 

One  or  more  glasses  of  hot  water,  drunk  upon  arising, 
dissolves  and  washes  into  the  intestine  some  of  this  mucus. 
Alkaline  medicines,  also,  dissolve  the  mucus  to  a  certain 
extent,  though  not  as  much  as  some  enthusiastic  writers 
have  claimed. 

Lavage. — In  no  pathologic  condition  will  more  satis- 
factory results  be  obtained  than  by  the  proper  and  careful 
use  of  lavage  in  chronic  catarrhal  gastritis.  Indiscrimi- 
nately employed,  it  becomes  harmful,  and  by  its  unskillful 
and  injudicious  application,  lavage  has  been  made  the 
object  of  criticism  in  many  quarters. 

The  chief  indication  for  lavage  in  gastritis  is  the  presence 
of  mucus  in  such  excess  that  it  envelopes  the  food,  prevents 
its  saturation  by  the  gastric  juices,  and  impedes  the  orderly 


TREATMENT    OF    CHRONIC    GASTRITIS  419 

evacuation  of  the  stomach.  The  custom  of  washing  every 
stomach  in  which  small  amounts  of  mucus  are  found,  is 
rapidly  passing  away.  It  should  be  remembered  that  a 
thin  mucous  coating  of  the  lining  of  the  stomach  is  a  pro- 
tection against  irritating  food  and  gastric  juice  of  height- 
ened acidity,  and  with  all  this  washed  away,  the  stomach 
is  more  susceptible  to  pathologic  influences. 

Frequency  of  Lavage. — Once  daily  is  sufficient,  unless 
there  is  also  stagnation  and  fermentation,  in  which  event 
the  mucus  may  be  washed  out  in  the  morning,  and  the  fer- 
menting mass  be  washed  out  again  as  near  as  possible  to  the 
hour  for  retiring.  Daily  lavage  should  not  be  kept  up  long, 
and,  where  this  procedure  must  be  continued  for  several 
months,  two  or  three  times  weekly  is  an  ample  sufficiency. 
So  far  as  practicable,  the  lavage  should  be  performed  with 
the  stomach  free  from  food,  and,  if  required  to  clean  that 
viscus,  the  patient  should  assume  both  the  standing  and 
sitting  positions  while  the  operation  proceeds. 

The  solutions  employed  are  various,  depending  on  the 
condition  of  the  stomach  and  the  sensations  of  the  patient. 
It  is  well  to  first  wash  out  the  stomach  with  plain  warm 
water,  and  then  follow  with  the  medicament,  as  described 
in  the  chapter  on  local  treatment  of  the  stomach.  The  fol- 
lowing may  be  used:  i -grain  tablets  of  potassium  perman- 
ganate dissolved  in  i  pint  of  water,  sodium  bicarbonate, 
sodium  chlorid,  silver  nitrate,  5  grains  to  the  pint  of  water, 
calcined  magnesia,  ichthyol,  or  boric  acid.  In  those  of  a 
constipated  habit,  I  sometimes  leave  a  small  amount  of 
water  containing  a  heaping  teaspoonful  of  the  calcined 
magnesia  in  the  stomach. 

Electricity. — Except  in  cases  with  marked  atony  or  dila- 
tation, electricity  exerts  but  little  if  any  tangible  benefit. 
In  nervous  individuals,  however,  it  may  possess  some  psy- 
chic effect.  The  same  may  be  said  concerning  vibratory 
massage. 

Diet. — This  is  a  most  important  adjunct  to  the  manage- 
ment, and  the  patient  need  not  expect  permanent  improve- 


420  THE    GASTRITES,    ACUTE   AND    CHRONIC 

ment  unless  the  dietetic  injunctions  are  obeyed.  Let  me 
also  caution  the  physician  not  to  so  limit  the  food,  if  possible, 
that  the  patient  will  become  undernourished  and  with  it 
depressed  and  emotional.  The  stomach  is  capable  of  doing 
only  part  of  its  work,  while  an  extra  burden  is  imposed  upon 
the  small  intestine.  The  diet,  therefore,  must  be  so 
arranged  that  both  divisions  of  the  alimentary  tract  are 
protected.  A  diet  rich  in  carbohydrate  with  a  minimum  of 
protein  is  indicated.  In  chronic  gastritis,  especially  among 
those  who  necessarily  perform  manual  labor,  solid  foods 
may  be  permitted.  In  achylic  states  spices  and  condiments 
may  be  permitted  within  bounds,  and  the  diet  should  be  as 
varied  as  possible. 

Following  are  several  suggestive  dietaries  from  different 
well-known  sources,  which  may  be  modified  to  suit  particu- 
lar cases: 

DIET  FOR  CHRONIC  GASTRITIS  (EWALD) 

8  a.  m.  150  to  200  grm.  tea  with  75  to  100  grm.  stale 
white  bread,  toast,  or  zwieback. 

II  a.  m.  50  grm.  white  bread,  10  grm.  butter,  50  grm. 
cold  meat  or  ham,  1/3  liter  of  milk. 

2  p.  m.  150  to  200  grm.  water,  milk,  or  bouillon  of  the 
white  meats,  100  to  125  grm.  meat  or  fish,  80  to  100  grm. 
vegetables,  80  grm.  compot. 

4  or  5  p.  m.  1/4  to  1/3  liter  of  warm  milk  (occasionally 
mixed  with  cocoa  or  coffee) . 

7  or  8  p.  m.  200  grm.  soup  or  pap,  50  grm.  white  bread, 
10  grm.  butter. 

Occasionally  at  10  p.  m.  50  grm.  wheaten  bread 
(biscuits  or  zwieback),  one  cup  of  tea. 

DIET  FOR  FIRST  WEEK  OF  TREATMENT 
(EINHORN) 

8  a.  m.  Two  eggs,  60  grm.  French  white  bread,  15 
grm.  butter,  one  cup  of  tea,  10  grm.  sugar. 


DIET   FOR    CHRONIC    GASTRITIS  42 1 

10.30  a.  m.  250  grm.  koumiss,  matzoon,  or  milk,  30 
grm.  crackers,  20  grm.  butter. 

12.30  p.  m.  2  ounces  tenderloin  steak  or  white  meat  of 
chicken,  100  grm.  mashed  potatoes  or  thick  rice,  60  grm. 
white  bread,  15  grm.  butter,  one  cup  of  cocoa. 

3.30  p.  m.     Same  as  10.30  a.  m. 

6.30  or  7  p.  m.  Farina,  hominy  or  rice  boiled  in  milk, 
one  liberal  plateful,  two  scrambled  eggs,  60  grm.  bread, 
15  grm.  butter. 

In  timing  the  distribution  of  meals  the  previous  habits  of 
the  patient  or  his  business  requirements  should  be  con- 
sidered. 

DIET  FOR  CHRONIC  GASTRITIS  (FRIEDEN- 
WALD  AND  RUHRAH) 

8  a.  m.  200  grm.  milk,  flavored  with  tea,  60  grm. 
stale  bread,  40  grm.  butter,  one  soft-boiled  egg. 

10  a.  m.  100  grm.  scraped  beef  with  60  grm.  stale  bread 
or  toast,  or  chicken  sandwich,  or  a  little  sherry  with  egg. 

12  m.  Bouillon  with  egg,  100  grm.  chicken,  100  grm. 
lamb  chops  or  broiled  steak,  100  grm.  spinach,  100  grm. 
mashed  potatoes,  100  grm.  stewed  apples,  60  grm.  toast. 

4  p.  m.      120  grm.  milk,  with  tea,  30  grm.  crackers. 

7  p.  m.  60  grm.  stale  bread  with  40  grm.  butter,  200 
grm.  milk. 

In  the  various  manifestations  of  gastritis  the  motor  and 
secretory  functions  must  be  separately  considered,  and  a 
diet  should  be  ordered  which  in  quantity  conserves  the 
motor  power,  and  which  in  quality  conserves  the  digestive 
juices,  if  any  be  present. 

Should  hyperacidity  of  a  marked  type  exist,  proteins  and 
fats  somewhat  in  excess  of  the  usual  amount  may  be  per- 
mitted. In  achylia  the  diet  should  theoretically  consist  of 
carbohydrates  and  starches  with  a  minimum  of  proteins 
and  fats.  Practically,  some  proteins  are  allowable,  unless 
for  a  special  reason,  and  the  patient  generally  is  none  the 
worse  for  them. 


42  2  THE    GASTRITES,    ACUTE    AND    CHRONIC 

Medicinal  Treatment. — ^This  must  be  governed  by  cir- 
cumstances, remembering  that,  except  for  the  management 
of  symptoms,  it  is  not  well  to  institute  a  medical  regimen 
that  may  extend  over  many  months.  In  hyperacid  con- 
ditions gentle  alkalies  may  be  administered,  and  gentle 
laxatives  may  be  combined  with  them.  The  ordinary 
alkaline  and  carminative  prescriptions  indicated  in  hyper- 
chlorhydria  are  often  most  efficaceous  and  comforting  to 
the  patient.  For  the  occasional  sensitiveness  of  the  gastric 
mucosa  there  may  be  given  olive  oil,  oil  of  sweet  almonds, 
or  liquid  albolene,  in  teaspoonful  doses,  a  short  while  before 
meals. 

In  subacid  or  achylic  conditions,  small  doses  of  dilute 
hydrochloric  acid  (six  to  ten  drops)  may  be  given  after 
meals,  and,  if  desired,  this  acid  may  be  combined  with 
pepsin,  or  nux  vomica.  The  administration  of  huge  doses 
of  hydrochloric  acid  (sixty  drops),  as  advocated  by  some, 
is  not  endorsed  by  me.  Before  meals,  there  may  be  given 
with  propriety  and  benefit  the  bitter  stomachics,  as  con- 
durango,  quassia,  or  cinchona.  Three-grain  doses  of  orexin, 
given  one  and  a  half  or  two  hours  before  meals  often  exer- 
cise a  stimulating  effect  upon  achylic  stomachs.  Acidol 
tablets  and  tablets  of  secretin  are  highly  esteemed  by  some 
observers. 

Mineral  Waters.- — The  treatment  of  chronic  gastritis 
by  the  employment  of  mineral  waters,  or  balneological 
measures,  is  much  more  in  vogue  in  Europe  than  in  this 
country,  though  under  proper  advice  and  supervision  ex- 
cellent results  are  sometimes  attained. 

Different  waters  may  be  utilized  for  stimulating  glandu- 
lar activity,  or  neutralizing  high  acid  secretions,  as  the  case 
may  be.  To  stimulate  secretion,  the  saline  waters  and 
those  containing  carbonic  acid  gas  are  of  most  service. 
Among  these  may  be  mentioned  Kissingen  (Racozy), 
Kochbrunner,  Homburg,  Fachingen  Soden,  or  the  American 
carbonic  acid  charged  waters  of  Saratoga  (Congress  spring). 


ALCOHOLIC    GASTRITIS  423 

When  the  gastric  secretion  is  absent  these  waters  are  of  no 
benefit. 

In  hyperacidity  the  alkaline  waters  are  useful,  among 
these  being  Vichy,  Celestine,  Weisbaden  (Kochbrunnen), 
St.  Galmier,  and  Saratoga  (Hathorn). 

In  the  presence  of  atony  there  may  be  used  with  caution 
Levico  Mild,  Mitterbad,  or  Schwalbacher. 

In  constipation  there  may  be  taken  Carlsbad,  Villabracas, 
Pluto,  or  Mt.  Clemens  bitter  water,  though  it  is  best  to 
bring  about  bowel  movements  by  dietetic  and  hygienic 
means. 

The  saline  waters  should  be  drunk  before  meals,  the  alka- 
line or  ferruginous  waters  during  or  after  meals.  The 
aperient  waters  should  be  taken  on  an  empty  stomach, 
preferably  on  arising.  Patients  of  a  nervous  or  debilitated 
nature  should  not  be  allowed  to  partake  of  purgative  water. 

The  reason  that  sojourners  at  foreign  spas  or  at  mineral 
springs  in  this  country  improve  so  markedly  in  so  many 
instances,  is  not  so  much  because  of  any  great  virtue  in  the 
water,  as  because  of  the  freedom  from  business  cares  and 
worries,  the  exercise  in  the  open  air,  the  change  of  environ- 
ment, and  the  diversion  of  the  mind  to  outward  interests. 
It  should  not  be  forgotten  that  the  daily  ingestion  of  copious 
draughts  of  water  causes  a  steady  washing  out  of  the  stom- 
ach and  emunctories  of  the  whole  body,  so  that  the  sufferer 
is  greatly  benefitted  thereby. 

ALCOHOLIC  GASTRITIS 

This  form  manifests  itself  somewhat  differently  from  the 
other  forms,  and  requires  somewhat  different  treatment. 
It  is  generally  brought  on  by  indulgence  in  alcoholic  de- 
bauches more  than  in  regular  use  of  the  different  forms  of 
alcohol  as  a  beverage,  and  is  specially  prone  to  appear  when 
cheaper  brands  or  less  diluted  forms  of  whiskey  are 
consumed. 

In  this  form  of  gastritis  nausea  and  vomiting  predomi- 
nate,  appearing    soon  after   meals,  and  depending  to  an 


424  THE    GASTRITES,    ACUTE   AND    CHRONIC 

extent  upon  what  is  eaten.  This  nausea  is  less  when  Hquids 
or  bland  articles  are  taken.  With  this  nausea  is  a  decided 
repugnance  for  food,  the  patient  generally  desiring  whiskey 
alone,  and  he  finds  that  while  in  the  undiluted  form  it  hurts 
him  more,  it  is  more  easily  retained.  The  stomach  does 
not  always  become  quiet  when  empty,  but  distressing 
retching  keeps  up,  in  which  strings  of  ropy  mucus  are  gotten 
up  with  difficulty.  Another  rather  characteristic  symptom 
is  the  "morning  sickness,"  which  seems  relieved  only  by 
whiskey.  Thus  the  wretched  patient  is  constantly  im- 
pelled to  drink  that  which  injures  him  most  and  keeps  alive 
the  fire  of  gastric  distress. 

The  test-meal  does  not  disclose  any  special  signs,  and 
occasionally  fairly  normal  test-meals  may  be  obtained  from 
alcoholic  patients  in  whom  severe  clinical  symptoms  are 
manifest.  Long-continued  cases,  however,  with  many 
exacerbations,  may  result  in  complete  achylia.  Achylia, 
too,  is  generally  present  when  the  liver  is  cirrhosed. 

Treatment. — The  outlook  naturally  depends  upon  the 
patient's  habits,  for,  if  complete  abstention  from  all  forms 
of  alcoholic  intoxicants  may  be  secured,  the  chances  for 
recovery  are  bright,  although  the  deep  pathologic  changes 
will  of  course  persist. 

In  some  cases  it  seems  impossible  to  stop  the  stimulant 
at  once,  though  this  is  always  theoretically  indicated.  I 
have  found  in  many  instances,  that  the  following  prescrip- 
tion given  in  but  little  water,  will  to  some  extent  relieve  the 
craving  for  whiskey : 

I^.     Tr.  capsici, 

Tr.  gentianae  co aa    5iv. 

SiG. —  3i  in  water  every  3  hours. 

Also  may  be  given: 

I^.     Spts.  ammonice  arom §i. 

SiG. — One  teaspoonful  in  water  every  one  to  three  hours. 

Should  there  be  threatened  delirium  tremens  with  occas- 
ional spasmodic  twitching  of  the  muscles,  the  hypodermic 


TREATMENT    OF    ALCOHOLIC    GASTRITIS  425 

use  of  1/50  grain  of  apomorphia  every  two  hours  will  bring 
both  quiet  and  relaxation.  This  should  not  be  continued 
if  nausea  is  increased.  For  the  nervousness  and  tremor,  I 
have  found  this  helpful : 

I^.     Cone.  tr.  passifloras  incarnatae, 

Elix.  ammoniae  valerianatis aa  i. 

SiG. — One  teaspoonful  in  water  every  one  or  two  hours. 

The  diet  should  be  bland  and  liquid  at  first,  though,  if  the 
food  is  retained  with  difficulty,  hot  soup  or  oyster  stew,  to 
which  is  added  plenty  of  black  pepper,  will  more  probably 
be  kept.  It  appears  that  these  overstimulated  stomachs 
require  highly  seasoned  foods  to  stimulate  the  juices,  and 
the  alcoholic  habitues  have  sometimes  learned  this  fact  by 
experience. 

The  unirritating  hypnotics  may  be  required  for  a  brief 
period,  but  should  be  promptly  discontinued  upon  conval- 
escence, or  another  pernicious  habit  may  be  formed. 

Gentle  salines  may  be  employed  to  empty  the  bowels,  and 
several  glasses  of  warm  water  may  be  taken  on  arising  when 
the  retching  is  ineffectual. 

In  addition,  all  the  resources  of  psychotherapy  should  be 
brought  into  play,  in  order  that  a  weakened  will  power  may 
assert  itself,  that  complete  and  lasting  abstention  from 
alcoholic  drinks  may  be  achieved,  and  with  bodily  and  ner- 
vous strength  may  also  be  gained  digestive  peace  and 
health. 


CHAPTER  XVII 

MOTOR  INSUFFICIENCY  AND  DILATATION 
OF  THE  STOMACH 

According  to  Stoker,  the  stomach  exercises  a  so-called 
double  motor  function,  namely  peristole  and  peristalsis. 
The  former  is  the  process  by  which  the  food,  as  it  reaches 
the  stomach  is  grasped  and  mixed  by  the  reflex  muscular 
action  of  the  fundus,  and  the  latter  consists  of  the  wave 
from  fundus  to  pylorus  driving  the  food  out  of  the  stomach. 
According  to  whether  one  or  both  of  the  above-named 
functions  of  the  stomach  are  disturbed,  and  also  according 
to  the  degree  of  the  disturbance,  we  differentiate : 

(i)  Hypotony,  or  motor  insufficiency  of  the  first  degree 
(Boas). 

(2)  Atony,  or  motor  insufficiency  of  the  second  degree 
(Boas). 

(3)  Gastrectasis,  due  to  mechanical  obstruction  at  the 
pylorus. 

Motor  insufficiency  of  the  first  degree  (myasthenia) 
depends  upon  a  primary  relaxation  of  the  muscular  wall  of 
the  stomach.  This  relaxation  may  result  from  bad  habits, 
gastronomic  excesses  frequently  committed,  or  prolonged 
use  of  narcotic  or  hypnotic  drugs.  We  also  find  this  form 
of  motor  insufficiency  with  or  following  grave  anemias, 
infections,  severe  hemorrhage,  childbirth,  chronic  gastritis, 
or  chronic  constipation. 

Diagnosis. — Atony  may  be  present  without  characteris- 
tic physical  signs,  unless  repeated  examinations  are  made, 
especially  two  or  three  hours  after  eating. 

To  the  observer  of  experience  much  is  learned  by  an 
inspection.  Stout,  robust-looking  individuals,  with  broad 
costal   angles  would   hardly  suggest  gastric  atony,  while 

426 


DIAGNOSIS    OF    MOTOR   INSUFFICIENCY  427 

delicate,  high-strung  individuals,  with  sharp  costal  angles 
are  particularly  susceptible  to  this  condition. 

An  atonic  stomach,  as  stressed  by  Lockwood,  need  not 
necessarily  be  a  large  stomach  at  all  times,  but  it  tends  to 
sag  upon  slight  provocation,  is  abnormally  distensible,  and 
varies  greatly  as  to  the  position  of  the  lower  border.  When 
the  patient  stands,  and  several  glasses  of  water  are  taken, 
the  lower  curvature  may  reach  2  or  more  inches  below  the 
umbilicus,  while  when  lying  down  and  the  stomach  is 
completely  empty,  the  whole  organ  may  lie  above  the 
umbilicus. 

The  normal  tonic  stomach  is  no  larger  than  its  contents, 
but  in  the  atonic  stomach,  splashing  may  readily  be  elicited, 
if  half  glass  of  water  is  taken  on  an  empty  stomach.  Excep- 
tion might  be  made  in  thin  primiparae  with  incompetent 
abdominal  walls.  In  atony  visible  peristalsis  is  never 
observed. 

The  radiographic  diagnosis  of  atony  is  most  helpful,  and 
is  based  on  the  examination  of  two  sets  of  plates,  one  taken 
directly  after  a  bismuth  test-meal  and  the  other  in  six  hours. 
Differentiation  must  be  made  from  pyloric  stenosis,  ulcer 
of  the  lesser  curvature,  cancer,  or  perigastric  adhesions 
limiting  free  motility.  Another  bismuth  meal  may  be  given 
after  the  six-hour  plate  has  been  taken,  which  will  accur- 
ately show  the  outline  of  the  filled  stomach.  The  second 
bismuth  suspension  meal,  given  after  the  first  six-hour 
plate,  will  demonstrate  the  different  appearances  of  the 
filled  stomach  as  shown  by  Holzknecht.  "This  classifi- 
cation," according  to  Holzknecht,  "gives  us  a  method  of 
testing  the  motility  of  the  stomach  far  in  advance  of 
anything  obtained  by  the  ordinary  clinical  methods.  As 
may  be  seen  in  the  diagrams,  the  normal  time  for  the  com- 
plete evacuation  of  the  stomach  varies  from  two  to  eight 
hours.  For  types  3  and  4  a  delay  of  six  hours  would  be 
normal,  whereas  for  type  i  it  would  indicate  some  obstruc- 
tion of  the  pylorus.  In  type  4  even  eight  hours  delay  would 
lead  to  no  suspicion  of  either  spasmodic  or  perm.anent  con- 


428  MOTOR   INSUFFICIENCY   AND   DILATATION 

tractions."  For  further  descriptions  of  radiographic  ap- 
pearances of  the  stomach,  the  reader  is  referred  to  the 
special  chapter  on  X-ray  diagnosis. 

Treatment. — This  should  be  regulated  upon  the  principle 
of  resting  the  stomach  muscles  and  improving  their  tonus. 
The  diet  should  be  so  adjusted  that  the  least  demands  are 
made  upon  the  motor  activity  of  the  stomach,  and  the  least 
weight  placed  upon  the  incompetent  supports.  The  meals 
should  be  small  in  quantity,  and  comparatively  frequent. 
Should  the  motor  power  be  quite  deficient,  either  liquid  or 
semi-solid  food  should  be  given  for  a  while.  Water  should 
be  drunk  in  plenty,  but  small  amounts  at  a  time.  The 
stomach  will  generally  be  found  to  easily  care  for  and  expel 
adequate  amounts  of  liquid,  so  they  are  taken  in  small 
quantities  at  a  time.  Milk  holds  the  foremost  place  in  the 
list  of  foods,  and  by  frequently  giving  a  glassful,  enough 
milk  alone  may  be  ingested  to  well  nourish  the  resting  body. 
In  cases  of  hypersecretion  or  hyperacidity  with  atony, 
Strauss  recommends  a  strictly  protein-fat  diet,  to  obviate 
the  carbohydrate  fermentation  which  would  otherwise 
result  from  insufficient  starch  digestion.  Protein  in  such 
cases  may  be  taken  in  solid  or  semi-solid  form,  but  it  should 
be  thoroughly  cooked.  In  subacid  conditions,  the  general 
principles  obtaining  in  the  treatment  of  subacid  gastritis 
also  apply.  The  diet  may  contain  a  large  proportion  of 
fat,  and  meats,  if  allowed,  should  be  finely  .subdivided  and 
well  masticated.  Eggs  may  be  allowed,  and  some  carbo- 
hydrates in  the  form  of  flour  soups,  leguminous  soups  or 
vegetable  purees,  all  of  which  should  contain  as  much 
butter  and  milk  as  possible.  Alcohol  should  be  prohibited, 
unless  in  the  form  of  very  small  quantities  of  mild  claret, 
and  only  then  as  a  compromise  to  one  who  is  perhaps 
habituated  to  the  use  of  strong  drink. 

Lavage. — This  is  not  specially  indicated  in  atony  of  the 
first  degree,  though  a  not  too  frequent  lavage  with  a  very 
weak  nitrate  of  silver  solution  may  be  of  benefit. 

Electricity  and  hydrotherapy  both  have  appropriate  uses. 


MOTOR    INSUFFICIENCY  429 

Medical  Treatment. — The  alkalies  are  naturally  indi- 
cated in  simple  atonic  cases  with  hyperacidity.  The  light 
calcined  magnesia  when  there  is  a  tendency  to  constipation, 
and  bismuth  or  heavy  magnesia  when  the  bowels  are  loos'i, 
may  be  given.  Bicarbonate  of  soda  should  not  be  given, 
as  it  produces  too  much  carbon  dioxide.  In  the  presence 
of  fermentation,  resorcinol,  salicylic  acid,  salol,  or  menthol 
may  be  combined  with  the  alkalies,  plus  suitable  carmina- 
tives for  the  eructations.  In  subacid  or  anacid  conditions, 
the  dilute  acids  may  be  given  in  small  doses  after  meals, 
while  nux  vomica,  condurango,  or  the  other  bitter  tonics 
may  be  administered  before  meals. 

MOTOR  INSUFFICIENCY  OF  THE  SECOND 
DEGREE 

This  is  also  called  chronic  dilatation  of  the  stomach, 
isochymia,  and  ectasia  ventriculi. 

We  must  not  commit  the  error  of  mistaking  gastroptosis 
for  dilatation.  With  the  former  the  upper  border  of  the 
stomach  descends  as  well  as  the  lower  border,  and  there  are 
generally  movable  kidney  and  enteroptosis.  The  prolapsed 
stomach  may  in  addition  be  dilated.  In  dilatation  the 
upper  border  does  not  descend,  but  maintains  its  relation 
with  the  diaphragm,  and  the  stomach  is  dilated  chiefly  in 
the  direction  to  which  the  greatest  force  is  applied,  down- 
wardly and  laterally.  Dilatation  may  also  ensue  in  the 
transverse  and  antero-posterior  dimensions,  and  the  pylorus 
may  be  a  little  further  to  the  right  and  in  a  slightly  lower 
plane,  but  the  lesser  curvature  maintains  its  relation  to  the 
diaphragm,  and  this  is  the  differential  point  betw^een  dilata- 
tion and  gastroptosis. 

In  insufficiency  of  the  second  degree  the  food  remains  in 
the  stomach  still  longer  than  when  the  peristole  alone  is 
disturbed,  and  with  the  dilatation  there  is  an  inability  to 
expel  its  contents  within  the  normal  limit  of  time.  Investi- 
gation has  shown  us  that  a  certain  amount  of  stenosis  of 


43  O  MOTOR   INSUFFICIENCY   AND   DILATATION 

the  pylorus  is  responsible  for  nearly  every  case  of  motor 
insufficiency  of  the  second  degree.  This  stenosis  may  re- 
sult from  various  causes,  but  it  is  nevertheless  there,  either 
periodically  or  continuously. 

Einhorn  uses  his  duodenal  bucket  of  different  sizes  to  test 
the  patency  of  the  pylorus.  This  is  swallowed,  allowed  to 
remain  over  night,  and  on  being  withdra.wn  the  next  morn- 
ing, is  examined  for  pancreatic  ferments,  which,  if  found, 
show  that  the  pylorus  is  patent.  Einhorn  has  also  drawn 
attention  to  the  fact  that,  if  there  be  an  ulcer  in  the  tract 
traversed  by  the  cord,  the  silk  will  be  blackened  and  dis- 
colored at  that  point,  affording  a  clue  to  the  site  of  the  ulcer. 

Diagnosis.  Atonic  Type. — In  this  condition  the  symp- 
toms are  not  always  referred  to  the  stomach,  but  just  as 
often  to  the  nervous  system,  and  the  patient  is  prone  to 
become  melancholic  or  neurasthenic.  There  is  frequent 
belching,  and  a  sense  of  uneasiness  in  the  epigastrium,  but 
acute  dyspeptic  symptoms  may  be  absent.  Occasionally, 
in  extreme  dilatation,  there  may  be  vomiting  of  large 
quantities  of  fluid,  but  not  as  much  as  in  the  stenotic  type. 
Chronic  gastritis  with  the  attendant  symptoms  are  some- 
times associated;  rarely  hyper chlorhydria. 

The  gastric  findings  are  variable;  fermentation  is  fre- 
quent, while  subacidity  or  absence  of  hydrochloric  acid  is 
often  the  case;  hyperacidity  is  seldom  noted,  while  Kemp 
reports  a  few  instances  of  achylia. 

Stenotic  Type. — This  may  be  congenital,  or  acquired 
from  ulcer,  cicatrices  following  burns  from  acids  or  alkalies ; 
from  severe  gastritis  producing  hypertrophy  at  the  pylorus ; 
repeated  pylorospasm  from  extreme  acidity ;  pressure  from 
large  gall-stones;  perigastric  adhesions;  sclerosis  in  the 
pyloric  end  of  the  stomach ;  and  often  a  stenosis  from  begin- 
ning or  slightly  advanced  malignant  disease  of  the  pylorus. 
Secondary  dilatation  may  also  arise  from  decided  stricture 
of  the  duodenum  or  a  kink  there  from  "water- trap" 
stomach. 

The  symptoms   of   dilatation  of   the   stomach   due  to 


STENOSIS    OF    THE    PYLORUS  43 1 

pyloric  obstruction  are  quite  characteristic,  being  modified 
when  malignancy  is  a  factor.  When  congenital,  they  come 
on  directly  after  birth,  or  a  few  weeks  later,  depending  on 
the  degree  of  stenosis.  There  are  present  wasting,  pro- 
jectile vomiting,  visible  gastric  peristaltic  waves,  non-fecal 
bowel  movements,  and  in  some  instances  a  palpable  tumor 
in  the  region  of  the  pylorus.  Projectile  vomiting,  occurring 
early  in  an  otherwise  healthy  appearing  infant,  when  the 
mother's  milk  is  normal,  should  quickly  excite  suspicion  of 
congenital  pyloric  stenosis.  In  other  cases,  where  there 
can  be  detected  no  pyloric  thickening,  where  the  bowel 
movements  are  occasionally  fecal,  and  where,  in  spite  of  the 
projectile  vomiting,  there  is  no  rapid  loss  of  weight,  the 
condition  is  probably  due  to  pylorospasm.  Many  of  these 
latter  cases  are  wrongly  diagnosed,  being  considered  cases  of 
difficult  feeding. 

Acquired  Stenosis  of  the  Pylorus. — ^These  symptoms  are 
thirst,  dryness  of  the  throat,  dry  skin,  cramp-like  pains  of 
considerable  severity,  peristaltic  restlessness  of  the  stomach, 
and  vomiting  of  much  chyme,  often  containing  remnants 
of  food  taken  the  day  before,  or  even  several  days  before. 
The  bowels  are  constipated,  and  emaciation  rapidly  super- 
venes. Intestinal  fermentation  and  putrefaction  with  indi- 
canuria  are  often  present. 

The  benign  type  of  stenotic  dilatation  may  pursue  rather 
a  long  course,  w4th  periods  of  improvement  under  appro- 
priate treatment,  but  with  a  tendency  to  relapse. 

In  the  malignant  type  there  is  marked  cachexia,  rapid 
emaciation,  either  coffee-ground  vomitus  or  that  with 
occult  blood,  free  hydrochloric  acid  diminished  or  absent, 
lactic  acid  and  Boas-Oppler  bacilli  present,  undigested 
meat,  and  the  age  of  the  patient  forty-five  or  over.  A 
confident  diagnosis  of  malignant  stenosis  is  justified, 
under  such  conditions. 

Einhorn  directs  the  patient  to  eat  a  supper  containing  a 
liberal  quantity  of  rice  and  raisins.  If  these  two  foods  are 
still  in  the  stomach  in  appreciable  quantities  the  following 


432 


MOTOR    INSUFFICIENCY    AND    DILATATION 


morning,  he  diagnoses  marked  stenosis  of  the  pylorus. 
Weinstein  asserts  that  any  patient  in  whom  a  considerable 
proportion  of  a  mixed  meal  is  found  in  the  stomach  seven  or 
eight  hours  after  eating  it,  is  affected  with  pyloric  stenosis. 
Treatment. — The  acute  cases  of  congenital  stenosis  in 
young  infants  should  receive  prompt  surgical  attention. 
Other  treatment  is  futile,  and  the  reported  cures  have  prob- 
ably been  cases  of  pylorospasm. 


Fig.  71. — Boas-Oppler  bacilli.     (Hemmeter.) 


Atonic  dilatation  is  by  far  the  most  frequent  condition 
that  calls  for  treatment,  being  found  among  those  who  are 
hearty,  and  rapid  eaters,  or  who  drink  immense  quantities 
of  fluid,  fermented  or  otherwise.  Associated  with  this  we 
often  find  disturbed  acidity  or  chronic  gastritis. 

Dietetic  regulations  are  important,  and  a  light,  rather 
dry  diet,  as  in  chronic  gastritis  is  proper,  with  modifications 
suited  to  the  amount  of  acid  and  other  juices  secreted. 
Sufficient  water  should  be  allowed,  but  in  moderate  quan- 
tities at  a  time. 

Orthopedic  Treatment. — In  this  form  of  dilatation, 
unless  there  is  stenosis  of  marked  degree,  the  supportive 
measures  described  in  a  preceding  chapter  will  be  found 
most  useful.     I  have  in  many  instances  em;^oyed  the  Rose 


TREATMENT  OF  MOTOR  INSUFFICIENCY         433 

adhesive  plaster  belt,  and  have  been  able  to  demonstrate  a 
heightening  of  the  lower  border  of  the  stomach  by  2  or  more 
inches.  The  belt,  if  worn  several  weeks,  will  increase  intra- 
abdominal pressure,  and,  in  the  meanwhile,  if  the  patient  is 
well  and  appropriately  nourished,  a  certain  amount  of 
abdominal  fat  will  be  accumulated,  which  will  bring  about 
permanent  benefit.  Silk  and  elastic  abdominal  supports 
are  not  as  serviceable  as  the  adhesive  bandage  which  stays 
on  continuously. 

Hydrotherapy. — Much  assistance  may  be  obtained  from 
rational  hydrotherapy,  persistently  and  intelligently  ap- 
plied. Foolish  hydrotherapy  is  a  bane  from  which  many 
atonic  patients  suffer,  and  unless  proper  facilities  and  experi- 
enced attendants  are  available,  this  part  of  the  treatment 
had  best  be  omitted.  The  fan  and  Scotch  douche  applied 
to  the  epigastrium,  and  cold  compresses  and  sponging  are 
included  in  the  use  of  water. 

Lavage. — This,  too,  has  an  important  place  in  the  treat- 
ment, particularly  in  the  more  severe  cases  where  the  stom- 
ach is  emptied  with  difficulty,  and  some  fermenting  residue 
is  often  left  there.  It  is  best,  if  practicable,  to  thoroughly 
wash  out  the  stomach  just  before  bedtime,  as  the  muscles 
of  that  viscus  will  then  have  all  night  in  which  to  rest  and 
accumulate  renewed  tonus.  J.  W.  Weinstein  is  strongly 
in  favor  of  lavage  at  this  time,  and  endeavors  to  see  his 
atonic  patients  as  late  as  possible  in  the  evening.  Should 
this  period  for  lavage  not  be  convenient,  the  early  morning 
hours  before  food  is  taken  are  next  best.  The  aim  is  to  wash 
out  superfluous  mucus  but  not  food,  for  if  too  much  of  the 
nourishment  is  lost  with  the  lavage,  the  patient  suffers  in 
nutrition. 

In  cases  of  subacidity  with  fermentation  I  use  in  the 
lavage  one  of  the  several  antiseptics  previously  mentioned, 
as  potassium  permanganate,  ichthyol,  liquor  alkaline  anti- 
septic (N.  F.),  or  even  creolin.  In  hyperacid  cases  I  use 
calcined  magnesia,  soda  bicarbonate,  boric  acid,  or  lime 
water.  In  constipated  habit,  I  allow  one  or  more  teaspoon- 
28 


434  MOTOR   INSUrriCIENCY   AND   DILATATION 

fuls  of  calcined  magnesia  mixed  with  the  last  half  pint  of 
water  to  remain  in  the  stomach.  This  generally  exerts  a 
mild  and  pleasant  hydragogue  cathartic  eJffect. 

Electricity,  massage,  and  systematic  methods  of  exercise 
have  their  proper  and  useful  place  in  the  treatment  of  this 
diseased  state,  but  none  of  these  should  be  attempted 
except  under  competent  advice.  I  often  have  these  suf- 
ferers consult  me  who  report  various  bizarre  exercises 
taken  upon  the  suggestion  of  zealous  but  ignorant  friends, 
and  find  that  they  have  sustained  injury  thereby. 

Medication. — Acids,  if  subacidity  is  present;  alkalies,  if 
hyperacidity  is  found;  bitter  and  ferruginous  tonics,  if 
anemia  be  in  evidence ;  gentle  laxatives  or  enemas  for  con- 
stipation; stomachics  before  meals,  if  the  appetite  is  lack- 
ing; nerve  sedatives  (not  habit -forming  ones)  for  unstable 
and  distressed  nerves — all  these  are  indicated  in  motor 
insufficiency  of  the  second  degree. 

Treatment  of  Stenotic  Dilatation  (Non -malignant). — 
The  treatment  afforded  this  condition  by  the  internist  is 
at  best  only  palliative.  No  roseate  promises  of  permanent 
improvement  can  be  honestly  given,  for  they  must  look 
to  surgery  for  relief. 

If  for  any  reason  surgery  cannot  be  obtained,  frequent 
lavage,  duodenal  or  rectal  feeding,  and  the  administration 
of  either  olive  oil  or  liquid  albolene  are  the  best  that  medical 
aid  can  offer.  If  the  pylorus  is  not  entirely  obstructed, 
liquid  food  may  be  given,  and  if  the  patient  will  lie  on  his 
right  side  for  an  hour  or  more  afterward,  much  of  it  may 
pass  the  pylorus.  Einhorn  has  recommended  his  pyloric 
dilator,  but  its  use  will  seldom  be  found  possible,  and, 
while  efforts  are  being  made  in  this  direction,  valuable  time 
is  lost.  Unless  there  is  some  positive  contraindication  to 
surgery,  the  patient  should  seek  that  form  of  aid ;  any  other 
form  of  therapy  is  simply  dalliance  with  disease. 

Malignant  Stenosis  will  be  discussed  under  cancer  of  the 
stomach. 


ACUTE   DILATATION   OF    THE    STOMACH  435 

ACUTE  DILATATION  OF  THE  STOMACH 

This  is  also  called  acute  gastrectasis,  post-operative 
gastric  dilatation,  duodenal  ileus,  and  mesenteric  ileus. 

Formeriy  it  was  believed  to  be  rare,  but  it  is  now  con- 
sidered somewhat  frequent,  and  many  cases  of  post-opera- 
tive vomiting  and  collapse  are  now  thought  to  be  due  to 
this  condition. 

There  are  many  conflicting  views  as  to  the  cause  of  this 
acute  and  alarming  condition,  but  a  reasonable  consensus 
of  opinion  is  thus  summarized  by  Lockwood. 

(i)  In  rare  instances  mechanical  dilatation  of  the  stom- 
ach may  be  induced  by  excessive  eating  or  drinking,  either 
by  causing  a  paralytic  overdistention  or  by  mechanical 
pressure  of  the  overloaded  stomach  upon  the  duodenum. 

(2)  Mechanical  pressure  of  the  stomach  on  the  duodenum 
is  favored  by  counter-pressure  of  the  abdominal  wall, 
explaining  the  relative  frequency  with  which  the  accident 
has  occurred  after  the  encasement  of  the  body  by  a  plaster 
jacket  in  orthopedic  cases. 

(3)  Arterio-mesenteric  constriction  by  traction  of  the 
root  of  the  mesentery  from  downward  displacement  of  the 
intestine  may  occur  in  rare  instances  as  a  primary  cause  for 
acute  dilatation,  although  when  the  stomach  is  dilated  the 
enlargement  of  the  organ  tends  to  push  the  intestines  down- 
ward, and  to  create  a  mesenteric  pull  that  is  quite  enough 
to  keep  up  an  obstruction  after  it  has  once  started.  This 
view  implies,  therefore,  that  in  the  very  great  majority  of 
instances  mesenteric  constriction  is  a  secondary  factor  in 
the  production  of  an  acute  dilatation. 

(4)  The  same  may  be  said  of  mechanical  obstruction  of 
the  duodenum  by  the  pressure  of  an  overloaded  stomach  on 
the  duodenum;  in  the  majority  of  instances  the  dilatation 
is  the  first  event  and  the  mechanical  pressure  of  the  stomach 
is  an  entirely  secondary  affair. 

(5)  Diminished    motor   innervation    by   paresis    of    the 


436  MOTOR   INSUFFICIENCY   AND   DILATATION 

vagus  is   plausible  to   explain   acute   dilatation  following 
head  injuries. 

(6)  Lowered  tone  of  the  vomiting  centers  after  anesthesia 
as  a  cause  may  be  considered  doubtful. 

(7)  Dilatation  of  the  stomach  may  be  increased  after  the 
process  has  once  started,  by  closure  of  the  cardia  either  by 
valve-like  folds  of  nucous  membrane  or  by  lateral  intra- 
gastric pressure  on  an  oblique  insertion  of  the  esophagus.  ' 

(8)  Probably  the  most  potent  cause  for  acute  dilatation 
is  a  paralytic  relaxation  of  the  gastric  wall  due  to  the  effect 
of  various  toxins,  in  infectious  diseases  and  in  septic  condi- 
tions. A  primary  dilatation  so  induced  may  lead  to  a  cer- 
tain degree  of  mesenteric  constriction  which  is  often  a 
marked  contributory  factor. 

(9)  Local  peritonitis  of  the  gastric  serosa  with  muscular 
relaxation  may  occur  after  abdominal  operations,  not 
sufficiently  intense  to  cause  septic  or  frank  inflammatory 
symptoms,  but  quite  sufficient  to  induce  an  appreciable 
degree  of  dilatation,  which  may  be  further  increased,  should 
any  of  the  secondary  factors  for  dilatation  be  brought  into 
play. 

Diagnosis. — The  symptoms  are  quite  characteristic, 
pointing  plainly  to  the  acute  condition.  There  comes  on 
sudden  abdomxinal  distention,  pain,  tenderness,  excessive 
vomiting,  constipation,  thirst,  scanty  urine,  and  collapse. 
The  onset  is  nearly  always  sudden,  and  the  vomiting  is 
profuse,  coming  up  in  great  gulps  without  straining.  At 
first  the  vomitus  may  consist  of  gastric  contents,  but  later 
it  becomes  watery  and  of  a  greenish  hue.  Sometimes  the 
vomitus  may  take  on  a  foul  and  feculent  odor. 

Pain  is  generally  present  in  the  epigastric  and  umbilical 
region,  sometimes  being  suggestive  of  peritonitis.  This  is 
followed  by  a  sense  of  distention  with  accompanying 
cardio-respiratory  symptoms.  Muscular  rigidity  is  absent, 
though  there  may  be  general  abdominal  tenderness.  Hic- 
cough may  occur  as  a  terminal  symptom. 

In  the  gastric  or  gastroduodenal  type  there  is  distention 


TREATMENT    OF    ACUTE    DILATATION  437 

of  the  abdomen,  but  not  uniform,  chiefly  filKng  the  left  half 
and  lower  part  of  the  abdomen,  while  the  right  hypo- 
chondrium  appears  to  be  flattened.  The  epigastrium,  too, 
is  often  swollen. 

Splashing  sounds  (succussion)  and  the  sense  of  fluctuation 
can  often  be  made  out,  though  they  are  not  always  present 
at  first  when  there  is  chiefly  gas  in  the  stomach. 

Percussion  will  show  the  resonance  increased,  but  will  be 
interfered  with  when  there  is  much  fluid.  Percussion, 
therefore,  is  important  when  the  splash  is  absent. 

The  general  symptoms  are  those  of  collapse,  a  rapid  and 
small  pulse,  frequent  and  troubled  respiration,  and  a  sub- 
normal temperature. 

One  of  the  main  diagnostic  points,  however,  is  the  passage 
of  the  stomach-tube,  when  the  escape  of  air  in  large  quanti- 
ties, the  outflow  of  fluid  of  the  character  previously  de- 
scribed, and  the  flattening  of  the  epigastrium  following  this, 
are  signs  of  the  greatest  significance,  especially  if  the  patient 
has  undergone  a  previous  operation. 

Prognosis. — This  is  grave,  about  a  72  per  cent,  death  rate 
being  recorded.  If  the  diagnosis  can  be  promptly  made, 
and  suitable  and  energetic  measures  be  at  once  instituted, 
there  is  a  moderate  outlook  for  recovery. 

Treatment. — Distention  following  operations  should  re- 
ceive immediate  treatment  by  lavage  and  enteroclysis,  and 
both  should  be  expertly  done,  not  being  left  to  the  discre- 
tion of  some  inexperienced  assistant.  It  is  radically  wrong 
to  wait  until  the  symptoms  are  marked  or  until  projectile 
vomiting  ensues  before  lavage  is  instituted.  The  stomach 
may  redistend  in  severe  cases. 

Lavage  should  be  given  two  or  three  times  about  three 
hours  apart,  and  thereafter  every  four  of  six  hours  during 
the  first  twenty-four  hours.  It  may  need  to  be  kept  up 
for  several  days,  and  it  is  better  to  err  by  washing  the  stom- 
ach too  much  than  too  little. 

No  food  or  drink  should  be  given  by  the  mouth.  For 
severe  thirst  saline  enemata   or  proctoclysis  must  answer, 


438  MOTOR   INSUmCIENCY  AND   DILATATION 

and  rectal  feeding  must  be  kept  up  for  several  days  after 
the  symptoms  disappear. 

Should  there  be  indications  of  intestinal  distention  or 
obstruction,  continuous  proctoclysis  with  a  normal  saline 
solution  at  120°  F.  is  of  value.  In  some  instances  there 
may  be  given  an  ounce  of  sulphate  of  magnesia  by  a  high 
enema. 

The  posture  of  the  patient  is  important,  and  should  be 
semi-oblique  or  nearly  in  the  sitting  position.  The  head 
of  the  bed  should  be  elevated  so  the  patient  lies  on  an  in- 
clined plane.  Elevation  of  the  foot  of  the  bed  has  been 
recommended  in  acute  dilatation  of  the  duodenum,  but 
this  entails  a  dangerous  pressure  on  the  heart  and  lungs, 
should  the  stomach  redilate. 

Medicinal  Treatment. — This  is  mainly  symptomatic, 
though  eserin  in  i/ioo-grain  doses  is  generally  given  to 
promote  intestinal  peristalsis.  Strychnin,  atropin,  or  bella- 
donna may  be  administered  as  indicated.  The  employ- 
ment of  apomorphia  to  produce  emesis  is  to  be  condemned. 

Surgical  interference  is  now  considered  inadvisable  by 
the  majority,  and  the  only  excuse  for  surgery  lies  in  those 
post-operative  cases  in  which  a  differential  diagnosis  be- 
tween acute  dilatation  and  acute  obstruction  by  reason  of 
adhesions  and  kinks  is  impossible  to  be  made.  Under  these 
circumstances  the  surgeon  is  sometimes  justified  in  per- 
forming an  exploratory  laparotomy. 


CHAPTER  XVIII 
HEMATEMESIS— ULCER  OF  THE  STOMACH 

There  are  few  symptoms  more  dramatic  or  fear  inspiring 
than  the  escape  of  blood  from  the  mouth.  Patients  will 
bear  without  treatment  many  painful  or  exhausting  ail- 
ments for  a  time  without  seeking  medical  rehef ,  but  when 
hematemesis  appears,  no  matter  what  cult  they  may  sub- 
scribe to  in  health,  they  will  at  once,  and  urgently,  seek 
medical  aid.  It  is  well,  therefore,  to  briefly  mention  the 
causes  of  gastric  hemorrhage,  and  the  treatment. 

The  physician  should  not  be  deceived  by  vomitus  colored 
by  previously  ingested  berries,  dark  wine,  or  iron  prepara- 
tions, nor  should  he  forget  that  the  hemorrhage  may  arise 
from  blood  originating  in  the  post-nasal  space  or  lungs,  and 
swallowed  during  sleep. 

These  factors  being  eliminated,  the  causes  of  gastric 
hemorrhage  may  be  classified  as  follows : 

(i)  Trauma  over  the  stomach,  or  injuries  to  the  mucosa 
from  swallowed  articles  which  may  cut  or  bruise  the  inner 
walls  of  the  stomach. 

(2)  Thrombosis  or  embolism  of  the  vessels,  varicosities, 
or  esophageal  varices. 

(3)  Lesions  of  the  heart  or  lungs  producing  stasis  in  the 
vena  cava. 

(4)  Constitutional  diseases,  as  lukemia,  pernicious  ane- 
mia, hemophiHa,  scurvy,  or  purpura  hemorrhagica. 

(5)  Hematemesis  as  a  type  of  vicarious  menstruation. 

(6)  Ulcer  of  the  stomach,  erosions  of  the  stomach,  car- 
cinoma. 

(7)  Acute  infectious  diseases,  as  yellow  fever,  hemor- 
rhagic malarial  fever,  scarlet  fever,  measles,  small-pox,  etc, 

(8)  Venous  stasis  due  to  cirrhosis  or  tumors  of  the  liver. 

439 


440  HEMATEMESIS ULCER    OF    THE    STOMACH 

Symptoms  and  Diagnosis. — The  main  symptom  is  the 
hematemesis  with  the  subsequent  melena.  If  much  blood 
is  lost,  either  vomited  or  expelled  into  the  bowel,  there  are 
the  usual  manifestations  of  pallor,  faintness,  blurred  vision, 
and  collapse,  with  cold  extremities  and  feeble  pulse.  If 
the  blood  is  small  in  amount  or  has  been  in  the  stomach 
for  a  time,  it  will  be  of  a  coffee-ground  color;  but  if  large  in 
amount  it  may  be  a  bright  red.  Sometimes  all  the  blood 
escapes  into  the  intestine,  and  then  until  the  melena  appears 
the  diagnosis  must  be  made  from  the  subjective  symptoms. 

Prognosis.' — This  is  rarely  fatal  from  the  first  hemor- 
rhage, but  should  impress  the  necessity  of  treating  the 
cause,  which  may  otherwise  progress  to  a  fatal  termination. 

Treatment.' — On  first  seeing  the  patient,  a  hypodermic  of 
morphin  should  at  once  be  given,  and  both  physical  and 
psychic  quiet  strictly  enjoined.  Following  this  an  ice-bag 
should  be  placed  over  the  epigastrium,  and  strychnin  may 
be  given  hypodermically  if  there  is  collapse. 

There  is  doubt  as  to  the  efficacy  of  drugs  given  by  the 
mouth  while  the  stomach  contains  blood,  but  as  a  matter  of 
routine,  and  one  which  can  do  no  harm,  the  following  is 
suggested:  A  lo  per  cent,  solution  of  gelatin,  2  drams  every 
half -hour;  lactate  or  chlorid  of  calcium,  15  grains,  or 
adrenalin  chlorid  (i :  1000)  five  to  ten  drops,  by  mouth  or 
hypodermic.  The  last-named  should  not  be  pushed  too 
far,  as  it  may  unduly  raise  the  blood  pressure  and  produce  a 
renewal  of  the  hemorrhage. 

The  patient  should  be  fed  by  rectum,  and  nothing  except 
small  pellets  of  ice  should  be  allowed  by  the  mouth  for  sev- 
eral days.  The  resumption  of  food  should  be  approached 
with  extreme  caution. 

ULCER  OF  THE  STOMACH 

This  lesion  is  also  called  peptic  ulcer,  ulcus  ventriculi, 
gastric  ulcer  and  round  ulcer. 

The  etiology  and  pathology  will  not  be  discussed,  as  to 


DIAGNOSIS    OF    ULCER    OF    STOMACH 


441 


adequately  cover  this  phase  of  the  subject  would  exceed  the 
scope  of  this  work. 

Diagnosis. — This  is  made  from  subjective  and  objective 
symptoms  and  chemical  findings. 

The-  patient,  generally  young  or  not  over  middle  aged, 
gives    a    history    of    systematic     indigestion,     heart-burn 


Fig.  72. — Tjqjical  pressure  point  in  gastric  ulcer.     (Cohnheim.) 


occurring  immediately  or  soon  after  eating,  cessation  or 
amelioration  of  the  pain  for  a  time  on  shifting  the  position 
so  that  the  contents  of  the  stomach  fall  away  from  the 
eroded  spot,  lack  of  cachexia,  epigastric  pain,  which  is 
greater  after  a  full  or  coarse  meal,  and  which  may  increase 


442  HEMATEMESIS — ULCER   OE    THE    STOMACH 

until  vomiting  empties  the  stomach.  These  symptoms 
excite  a  suspicion  of  gastric  ulcer,  and,  if  there  is  a  history  of 
hematemesis  or  melena  the  suspicion  is  strengthened. 

The  pain  is  one  of  the  most  suggestive  symptoms,  gener- 
ally occurring  a  few  minutes  after  eating  (occasionally  one 
or  two  hours  later) ,  and  persisting  during  digestion.  Liquid 
nourishment  produces  the  least  discomfort,  and  bland 
liquids  may  temporarily  ease  it.  The  pain  is  of  a  burning 
or  gnawing  character,  and  there  may  be  a  sensitive  epigas- 
tric point  which  is  increased  on  pressure.  Later  comes  the 
dorsal  pain,  gnawing  in  character,  lying  generally  to  the 
left  of  the  spine,  between  the  eighth  and  tenth  vertebra. 
This  dorsal  pain  may  alternate  with  the  epigastric. 

Appetite  is  variable,  though  many  patients  are  hungry 
indeed,  but  fear  to  eat  on  account  of  the  pain  that  ensues. 
Constipation  is  generally  in  evidence. 

As  the  ulcer  progresses,  hemorrhage  may  occur,  and  this 
is  visibly  present  in  from  one-third  to  one-half  of  the  cases, 
though  occult  hemorrhage  of  a  minor  degree  probably 
occurs  in  a  large  majority.  Should  the  symptoms  be  noted 
carefully,  and  frequent  tests  be  made  of  the  gastric  contents 
and  stools  both  chemically  and  microscopically,  I  believe 
blood  would  be  found  in  nearly  every  case.  The  hemor- 
rhage may  be  occult,  with  no  vomiting  of  blood,  but  this 
may  be  progressive,  and  the  patient  may  become  extremely 
anemic  from  small  and  repeated  losses. 

The  motor  functions  of  the  stomach  are  increased,  unless 
pyloric  stenosis  or  adhesions  complicate  the  ulcer. 

Examination  of  the  Stomach  Contents. — If  there  has 
been  a  recent  hemorrhage,  it  is  not  advisable  to  pass  the 
tube  for  ten  or  more  days,  but  otherwise  a  test-meal  Siiould 
be  taken.  Instead  of  the  Ewald-Boas  test-meal  it  is  prefer- 
able the  night  before  to  give  a  liberal  meal  of  potatoes,  rice, 
a  few  dried  raisins,  and  some  chopped  spinach,  and  on  the 
following  morning  the  Ewald-Boas  meal  may  be  given,  and 
aspirated  one  hour  later.  The  presence  of  raisins  and  rice 
would  indicate  motor  insufficiency  or  pyloric  obstruction. 


RADIOGRAPHIC   DIAGNOSIS    OF    ULCER  443 

In  about  95  per  cent,  of  acute  uncomplicated  cases  of 
ulcer  hyperchlorhydria  is  present,  the  free  acidity  running 
from  50  to  60,  or  even  more,  while  the  total  acidity  may  run 
from  90  to  150.  Sometimes  chronic  cases  of  long  duration 
do  not  show  hyperacidity,  and  some  have  been  reported 
where  achylia  was  present. 

The  absence  of  hyperchlorhydria  does  not  exclude  ulcer, 
and  we  must  bear  in  mind  the  possibility  of  there  being  a 
developing  cancer  on  the  base  of  an  ulcer.  The  presence  of 
occult  blood  is  a  strong  diagnostic  point  in  the  favor  of 
ulcer,  especially  when  fortified  by  clinical  history. 

Perforation,  with  concomitant  symptoms  of  shock  and 
perhaps  peritonitis,  and  later  on  subphrenic  abscess  are 
possible  complications  that  must  be  anticipated. 

Radiographic  Diagnosis  of  Ulcer. — If  it  were  the  fact  that 
the  base  of  an  ulcer  would  regularly  and  systematically 
retain  a  bismuth  coating  after  the  rest  of  the  meal  had  left 
the  stomach,  radiography  would  afford  an  easy  and  quick 
solution  of  the  question.  In  reality,  however,  the  ordinary 
cratiform  ulcer  does  not  hold  its  bismuth  coating  any  longer 
than  the  mucous  membrane  in  its  vicinity,  and  sometimes 
we  can  arrive  at  a  diagnosis  only  by  indirect  evidences,  and 
a  combination  of  clinical  history,  physical  examination  and 
chemical  analysis  taken  in  connection  with  the  plates.  The 
radiologist,  who  alone  and  without  the  aid  of  clinical  history 
attempts  to  arrive  at  a  diagnosis  of  gastric  ulcer  will  likely 
fall  into  error. 

The  following  technic  is  advised  by  Holzknecht  and 
Haudek.  The  patient  first  receives  an  efficient  cathartic, 
preferably  castor  oil,  given  at  night.  The  following  morn- 
ing at  a  specified  hour  the  Rieder  meal  is  taken,  consisting 
of  eight  ounces  of  oatmeal  gruel  into  which  is  well  mixed  2 
ounces  of  bismuth  sub-carbonate.  A  light  breakfast  of  tea 
and  toast  may  be  taken  one  hour  later,  if  desired.  The 
patient  should  be  at  the  radiologist's  office  in  sufficient 
time  that  the  first  exposure  may  be  made  at  exactly  six 
hours  after  the  bismuth  meal  has  been  taken.     This  will 


444  HEMATEMESIS — ULCER    OF    THE    STOMACH 

show  the  motihty  of  the  stomach  and  the  location  of  the 
bismuth  column.  A  second  bismuth  meal,  composed  of 
bismuth  i«  1/2  ounces,  and  mucilage  of  gum  acacia  2  ounces, 
to  which  is  added  water  enough  to  make  8  ounces,  is  then 
given,  and  a  second  radiograph  taken.  This  will  show  the 
size,  shape,  and  position  of  the  stomach.  Occasionally  a 
third  radiograph  may  be  taken  fifteen  minutes  later,  which 
will  show  the  motility  of  the  pylorus  and  the  first  part  of 
the  duodenum. 

The  following  radiographic  findings  may  be  considered 
suspicious  of  ulcer : 

A  displacement  of  the  pylorus  upward  and  to  the  left  is 
suspicious  of  ulcer  of  the  lesser  curvature,  which  may  cause 
contractions  along  the  upper  border  approximating  the 
cardia  and  the  pyloric  end.  This  is  called  the  ' '  snail  stom- 
ach." Hour-glass  contractions  appearing  in  all  the  plates 
are  suggestive  of  ulcer.  Distortion  or  displaceinents  of  the 
stomach  by  adhesions  suggest  the  presence  of  ulcer.  Pos- 
sibly the  most  suggestive  radiographic  appearance  is  that 
of  a  small  puckered  area  in  which  the  rugse  are  distorted. 
Where  the  bismuth  adheres  to  the  base  of  the  ulcer  after  the 
rest  of  the  meal  has  left  the  stomach,  the  radiologist  can  be 
almost  positive. 

Advisability  of  Medical  or  Surgical  Treatment. — This  is 
often  a  difficult  question  to  decide,  and  I  am  free  to  admit 
that  I  now  more  readily  refer  ulcer  cases  to  the  surgeon  than 
a  few  years  ago. 

The  mortality  of  ulcer  varies  greatly,  being  modified  by 
the  length  of  the  ulcer  history,  the  character,  and  the  facili- 
ties for  treatment.  Some  place  it  as  high  as  20  per  cent., 
while  the  late  Dr.  Musser  placed  the  mortality  in  private 
practice  at  about  3  and  in  hospital  practice  about  12  per 
cent.  The  position  of  the  ulcer  modifies  the  prognosis,  for, 
if  on  the  anterior  wall,  perforation  is  more  apt  to  occur. 

Leaving  out  the  dangers  from  hemorrhage  or  perforation, 
I  believe  that  the  acute  ulcers  or  those  of  moderate  chron- 
icity,  where  the  patient  can  be  managed,  and  proper  f acili- 


TREATMENT  OF  GASTRIC  ULCER  445 

ties  for  carrying  out  an  intelligent  line  of  treatment  are 
available,  offer  a  fairly  good  prospect  for  a  permanent  cure. 
The  chronic  ulcer,  as  a  rule,  should  be  referred  to  the  sur- 
geon, for  unless  it  is  possible  for  the  patient  to  undergo  a 
long  and  rigorous  course  of  medical  attention,  the  prospects 
of  permanent  relief  are  not  encouraging.  The  age  of  the 
patient  must  also  be  taken  into  consideration,  for  one  must 
never  forget  the  liability  of  later  development  of  cancer 
upon  the  scar  of  a  healed  ulcer,  and  when  the  patient  is  of 
middle  age  surgery  must  be  considered  more  readil}^ 

TREATMENT  OF  GASTRIC  ULCER 

General  Management.- — When  the  diagnosis  of  ulcer  has 
been  made,  and  medical  treatment  decided  upon,  the 
patient  should  be  put  to  bed,  and  under  a  strict  discipline  of 
rest,  diet,  hygiene,  and  suitable  medicine.  If  the  patient 
can  be  controlled  and  kept  in  bed  from  four  to  six  weeks, 
the  dangers  of  hemorrhage  and  perforation  are  minimized, 
and  the  outlook  for  a  cure  correspondingly  bright.  After 
the  time  has  passed  for  rest  in  bed,  the  transition  back  to 
walking  should  be  spread  over  about  two  weeks.  At  this 
time  (six  weeks  from  the  beginning  of  the  treatment) 
plain  and  substantial  fare  may  be  gradually  resumed, 
though  coarse,  irritating,  or  highly  seasoned  foods  should  be 
prohibited  for  a  long  space  of  time — indefinitely,  if  practi- 
cable. As  regards  beverages,  beer,  ale,  wine,  whiskey  and 
alcoholic  dfinks  of  all  sorts  should  be  interdicted,  as  well  as 
tea,  coffee,  and  the  stimulating  drinks  obtained  at  the  soda 
fountains.  Some  of  these  latter  " invigorators  "  which  are 
dispensed  under  a  harmless  guise  are  both  stimulating  and 
habit -forming. 

After  convalescence  is  well  established,  and  a  mixed  diet 
has  been  resumed,  rest  for  one  or  two  hours  after  each  meal 
should  be  insisted  upon,  and  all  troublous  topics  of  conver- 
sation avoided  while  digestion  is  actively  progressing.  If 
it  can  be  arranged,  a  sojourn  in  the  country  for  city  patients, 
or  in  the  city  for  country  patients  should  be  advised,  and  all 


446  HEMATEMESIS — ULCER   OF   THE    STOMACH 

the  habits  should  be  those  of  "the  simple  life."  During 
the  first  year  at  regular  intervals  analyses  of  the  gastric 
contents  and  feces  should  be  made,  so  that  hyperacidity  in 
the  former  or  occult  blood  in  either  may  receive  prompt  and 
appropriate  treatment,  if  discovered. 

Dietetic  Management  in  the  Treatment  of  Gastric 
Ulcer. — Concerning  this  there  are  divergent  views,  and  a 
rather  spirited  controversy  has  been  waged  between  several 
schools  of  thought  as  to  whether  this  management  should 
be  one  of  starvation  and  scant  fare,  liberal  feeding,  or  duo- 
denal alimentation.  Probably  no  one  rule  is  applicable  to 
all,  and  the  physical  condition  of  the  patient,  together 
with  the  manner  in  which  he  responds  to  the  treatment 
should  be  the  guide  for  at  least  the  beginning. 

In  so  far  as  the  stomach  is  concerned,  it  seems  that  the 
results  depend  upon  the  elements  of  gastric  and  pyloric 
spasm,  freshness  of  the  ulcer,  location  of  the  ulcer,  if  the 
duodenal  tube  is  to  be  used,  amount  of  bleeding  and  vomit- 
ing, and  the  general  excitability  of  the  viscus.  In  great 
irritability  rectal  feeding  should  at  least  be  inaugurated, 
though  occasionally  the  duodenal  tube,  by  short-circuiting 
the  food  directly  into  the  small  intestine,  and  removing  the 
irritation  from  a  sensitive  ulcer,  will  be  followed  by  a  quick 
cessation  of  all  these  symptoms.  As  a  rule  it  works  best  to 
inaugurate  the  von  Leube  treatment  for  the  first  few  days, 
then  cautiously  institute  and  follow  up  the  Lenhartz 
method,  unless  it  is  decided  to  employ  Einhorn's  method 
of  duodenal  alimentation. 

There  are  two  warnings,  which  Bassler  well  expresses: 
The  first,  that  if  resort  to  mouth  feeding  or  to  a  fuller  fare 
is  long  delayed  after  the  use  of  rectal  enemas,  a  distention 
of  the  stomach  with  a  sudden  increase  in  acidity  is  liable  to 
occur,  and  these  may  precipitate  vomiting,  and  directly 
or  indirectly  prevent  the  healing  of  the  ulcer.  The  second 
is,  that,  because  of  the  nature  and  quantities  of  food,  the 
Lenhartz  feeding  is  liable  to  keep  high  the  excess  acidity 
of  the  stomach,  and  in  this  way  a  cure  of  the  ulcer  is  wrought, 


TREATMENT  OF  GASTRIC  ULCER  447 

but  a  high  status  of  gastric  secretion  is  left,  which  mil- 
itates against  prophylaxis  of  a  return,  or  a  better  state  of 
stomach  condition  in  the  post-ulcer  period. 

The  dietetic  treatment  inaugurated  by  von  Leube,  and 
modified  somewhat  by  Ewald  is  described  by  the  latter  as 
follows : 

"For  the  first  three  days  absolutely  no  food  is  to  be  ad- 
ministered by  the  mouth,  but  a  nutritive  enema  is  given 
three  times  daily;  subsequently,  besides  the  enemata,  milk 
or  milk  in  flour  soup,  in  teaspoonful  doses  or  bland  chicken 
broth.     The  milk,  on  account  of  its  fine  fiocculent  coagu- 
lation, has  some  pegnin  added.     If  this  diet  is  well  borne, 
it  is  added  to  in  a  manner  to  be  described;  otherwise  abso- 
lute rectal  nutrition  is  again  instituted.     If  no  pain  follows 
the  careful  administration  of  milk,  we  may  permit  some- 
what larger  quantities  (up  to  a  flat  plateful),  leguminous 
flour  soup,  then  legumes;  later  pappy  food  made  of  chest- 
nuts, sago,  tapioca,  hygiama  and  others,  and  later  small 
quantities   of   milk.     Among   nutritive   substances    cows' 
milk  takes  first  place.     It  is  suitable  because  it  contains 
all  of  the  nutritive  elements  in  solution,  that  is,  finely  sub- 
divided, is  free  from  irritating  substances,  because  the  acid 
is  neutralized,  and  because  the  coagula  which  form  from 
the  action  of  the  gastric  juice  remain  soft.     The  patient, 
however,  must  drink  it  very  slowly  and  lukewarm.     To  pre- 
vent the  fiocculent  coagulation  of  milk,  and  the  irritation 
of  the  ulcerative  surfaces  due  to  this,  I  now  add  pegnin,  or 
lab-ferment,  which  produces  a  very  fine  fiocculent  coagula- 
tion.    Besides  pigeon  or  veal  soups,  the  yolk  of  an  egg,  or 
beaten-up  egg  albumen,   pulverized  meat  or  leguminous 
soups  may  perhaps  be  given.     We  must  limit  ourselves  to 
these  foods  until  the  severe  symptoms  have  disappeared. 
In  the  third  week  a  food  richer  than  this,  both  quantita- 
tively and  qualitatively,  is  permissible,  and  we  should  then 
carefully  try  food  of  somewhat  greater  consistence,  such 
as  scraped  raw  ham,  raw  or  very  soft  boiled  eggs,  scraped 
venison  or  breasts  of  fowls,  rolls  or  zwieback  softened  in 


44^  HEMATEMESIS ULCER    OF    THE    STOMACH 

cocoa,  but  milk  is  always  preferable,  and  we  should  always 
be  ready  to  return  to  a  simpler  diet  as  soon  as  the  symptoms, 
or  even  pains  appear." 

It  will  be  noted  that  this  diet  claims  as  its  main  feature 
stomach  rest,  and  that  no  particular  effort  is  made  to  supply 
caloric  values  equal  to  the  maintenance  of  nutrition,  nor  is 
any  special  attempt  made  to  encourage  the  repair  of  the 
ulcer  process.  This  diet  may  be  considered  a  conservative 
and  rational  combination  of  well-tried  methods,  and,  with 
certain  modifications  to  suit  individual  cases,  is  probably 
the  best. 

Arguing  from  the  fact  that  hyperchlorhydria,  chlorosis 
and  anemia  frequently  develop  in  the  course  of  ulcer, 
Lenhartz  has  advocated  quite  a  different  course  of  treat- 
ment, based  upon  a  different  assumption.  Even  in  cases 
of  hemorrhage  and  other  severe  symptoms,  Lenhartz  allows 
his  patients  from  the  start  to  take  concentrated  foods  rich 
in  albumen,  on  the  hypothesis  that  this  diet  converts  free 
hydrochloric  acid  into  the  loosely  combined  form,  and  pre- 
vents further  erosions  and  irritation  of  the  ulcerated  area. 

His  course  of  treatment  extends  over  two  weeks,  during 
which  time  absolute  rest  in  bed  is  required.  Local  applica- 
tions of  ice  bags  are  employed  during  the  first  ten  days. 
Lenhartz  also  recommends  the  use  of  bismuth  subcar- 
bonate  in  30-grain  doses  three  times  daily.  Chronic  ulcers 
with  decided  pain  are  treated  by  silver  nitrate  and  a  limita- 
tion of  liquids.  Bland  preparations  of  iron  are  given  if 
anemia  is  present.  The  following  articles  are  recommended 
by  Lenhartz:  Fresh  milk,  iced;  both  milk  and  eggs  placed 
in  a  glass  tumbler,  surrounded  with  cracked  ice,  and  kept  at. 
the  bedside^ — even  the  feeding  spoon  being  kept  iced  also. 
The  eggs  and  milk  may  be  given  alternately  in  hourly  doses, 
or  may  be  mixed  and  given  together.  Granulated  sugar  is 
added  to  the  eggs  after  the  third  day.  Raw  scraped  beef, 
boiled  rice  and  zwieback  are  given  later.  According  to  the 
following  schedule,  cooked  chicken,  finely  chopped,  or 
well-chopped  ham  or  beef  are  added  with  butter  and  given 


LENHARTZ    TREATMENT 


449 


in  large  doses.  After  the  tenth  day  broiled  chop  or  steak 
may  be  substituted  for  the  scraped  meat;  toasted  bread 
may  replace  the  zwieback,  and  fine  cereals  may  take  the 
place  of  the  rice.  During  the  first  ten  days  rigid  adherence 
to  the  prescribed  regimen  is  necessary,  both  as  regards  the 
quantity  of  each  article  given  at  each  feeding,  and  to  the 
totals  of  each  article  for  the  twenty-four  hours.  The  food 
is  given  in  hourly  intervals  from  7  a.  m.  to  9  p.  m.,  and 
a  complete  rest  of  10  hours  is  allowed  through  the  night. 
Beef  broths  are  contraindicated  owing  to  their  contained 
extractives  which  induce  hyperacidity.  Lenhartz  begins 
his  method  of  dieting  in  a  few  hours  after  severe  and 
repeated  hemorrhages,  and  claims  to  have  no  disastrous 
results  from  his  early  feeding.  It  might  be  said  in  this  con- 
nection, however,  that  few  clinicians  in  this  country  either 
advocate  or  employ  the  unmodified  Lenhartz  method  so 
soon  after  hemorrhage  as  the  originator  advocates. 


LENHARTZ  SCHEDULE 


Day  after  last  hematemesis 

I 

2 

3 

4 

S 

6 

7 

8 

9 

10 

II 

12 

13        14 

Eggs 

2 

3 

4 

20 

400 

S 
20 

500 

6 

30 

600 

7 

30 

700 

35 

8 

40 

800 

2X35 
100 

8 

40 

900 

2X35 

100 
20 

8 

SO 

1,000 

2X35 

200 

40 

8 

50 

1,000 

2X35 

200 
40 
50 
20 

2,478 

8 

50 

1,00c 

2X35 

300 
60 

/  SO 
40 

2,941 

8 

SO 

1,000 

2X35 

300 

60 

SO 

40 

2,941 

8 

SO 

1,000 

2X35 

300 

80 

SO 

40 

3,007 

8 

Milk........ 

Raw   scraped 
beef 

200 

300 

50 
1,000 

2X35 

Milk    cooked 

Ham  (raw) . . 

SO 

40 

3,073 

Butter 

Calories 

2801420 

637 

779 

9SS 

1. 135 

1,588 

1,721 

2,138 

The  eggs  and  milk  are  given  ice  cold  and  in  teaspoonfull  doses. 


In  this  treatment  Lenhartz  claims  a  mortality  of  2  or  3 
per  cent,  and  asserts  that  the  recurrence  of  hemorrhages. is 
less  frequent  than  in  any  other  form  of  treatment. 

It  might  be  fairly  stated  that  when  patients  are  reduced, 


29 


450  HEMATEMESIS — ULCER   OF   THE    STOMACH 

by  hemorrhage  or  previous  inabiHty  to  take  food,  the  Len- 
hartz  treatment  or  some  modification  may  be  employed. 
When,  though,  the  patient  is  in  fairly  good  physical  condi- 
tion, the  Leube  treatment  is  perhaps  safer. 

As  a  conservative  treatment  of  ulcer,  and  one  that 
well  suits  the  majority  of  patients  the  general  plan  of  Lock- 
wood  may  be  commended,  and  the  following  is  in  the 
main  as  he  carries  it  out : 

The  patient  is  kept  in  bed  for  four  weeks,  and  during  the 
first  ten  days  he  is  not  allowed  to  rise  to  either  drink  or  eat, 
or  to  evacuate  his  bowels  or  bladder. 

For  the  first  three  days  nothing  is  allowed  to  enter  the 
stomach,  whether  or  not  there  is  visible  or  occult  hemor- 
hage.  During  these  three  days  mouth  washes  are  used 
frequently,  to  minimize  mouth  sepsis  and  to  quench  the 
thirst.  A  cleansing  enema  is  given  early  in  the  first  day. 
Nutritive  enemas  are  not  employed,  nor  is  enteroclysis, 
except  in  the  case  of  those  who  are  weakened  by  hemor- 
rhages, insufficient  nourishment,  recurrent  vomiting,  or 
who  are  greatly  below  par.  Decinormal  solutions  of  so- 
dium bicarbonate  are  preferable  to  the  saline  solutions 
usually  recommended,  and  the  fluid  may  be  introduced  by 
the  Murphy  drop  method.  In  milder  cases  in  which  the 
only  indication  is  to  relieve  thirst,  retention  enemas  of  the 
soda  solution  may  be  given. 

Drugs  during  this  period  are  rarely  indicated,  exception 
being  made  in  the  case  of  recent  hematemesis,  or  continu- 
ous secretion  with  or  without  acid  vomiting. 

During  the  entire  treatment  hot  moist  applications  jare 
to  be  employed,  except  when  visible  hemorrhage  has 
occurred  at  any  time  within  the  previous  three  weeks,  and 
the  hotter  they  can  be  used  the  better.  While  considerable 
heat  is  desirable,  it  should  not  approach  a  degree  of  extreme 
discomfort.  The  electric  pad  is  quite  convenient,  and  the 
Priesnitz  application,  changed  every  hour  during  the  day 
and  twice  at  night,  is  also  easily  used.  These  external 
applications  should  last  during  the  four  weeks. 


TREATMENT    OF   ULCER  45 1 

In  cases  of  visible  hemorrhage,  ice-bags  are  to  be  appHed 
constantly  until  all  traces  of  blood  have  disappeared  from 
the  stools,  and  are  then  to  be  succeeded,  not  by  extreme 
heat,  but  by  the  Priesnitz  applications  warm  only,  and  reap- 
plied every  six  hours. 

Prom  the  fourth  to  the  seventh  day  feeding  by  the 
mouth  may  begin,  by  giving  peptonized  milk  in  2 -ounce 
doses,  and  a  similar  amount  of  Celestins  Vichy  or  of  a  so- 
lution of  sodium  bicarbonate  on  the  intervening  hours,  so 
that  the  patient  receives  2  ounces  of  liquid  every  hour. 
This  must  not  be  done  during  the  sleeping  hours.  On  the 
fifth  day  these  quantities  are  increased  to  3  ounces,  on  the 
sixth  day  to  5  ounces,  on  the  seventh  day  the  milk  is 
increased  to  7  or  8  ounces,  while  the  alkaline  water,  given 
at  the  alternate  periods,  is  reduced  in  quantity  to  suit  the 
patient. 

No  drugs  are  specially  indicated  at  this  period,  unless 
indicated  by  special  conditions  such  as  acidity,  vomiting  or 
hemorrhage.     The  bowels  are  moved  daily  by  s.  s.  enemas. 

During  the  second  week  the  diet  may  be  enlarged  by  the 
substitution  of  the  following  articles  for  any  of  the  doses  of 
milk;  junket,  arrowroot  gruel,  milk  toast,  creamed  maca- 
roni, malted  milk,  blanc  mange,  farina,  grits  or  cream  of 
wheat  with  cream  and  sugar.  Not  more  than  5  ounces  of 
any  one  of  these  should  be  given  at  any  one  time,  and  the 
system  of  two-hour  feeding  continued.  Only  one  article  is 
given  at  a  time.  Celestins  Vichy  or  the  soda  solution  may 
be  taken  as  often  as  desired,  but  not  in  greater  quantity 
than  four  ounces  at  one  time. 

During  the  third  week  the  only  change  is  the  enlarge- 
ment of  the  diet,  there  being  gradually  added  mashed  pota- 
toes, purees  of  any  kind  not  made  with  meat  stock,  creamed 
or  boiled  fresh  fish,  soft-boiled  or  poached  eggs,  the  soft 
part  of  pumpkin  pie,  custards  and  mashed  vegetables  that 
can  be  put  through  a  puree  sieve.  Soft  bread  or  crackers 
well  masticated,  are  allowed.  Several  articles  of  diet  may 
be  given  at  a  time,  and  the  feeding  interval  increased  to 


452  HEMATEMESIS ULCER    OF    THE    STOMACH 

three  hours.  At  this  time  milk  may  be  discontinued,  if 
desired. 

During  the  fourth  week  the  patient  is  allowed  to  sit  up  a 
portion  of  each  day,  while  the  external  applications  are 
gradually  diminished.  The  only  other  change  in  the  treat- 
ment is  the  addition  of  creamed  chicken,  tender  squab, 
lean  boiled  ham,  minced  veal. 

After  the  fourth  week  has  passed  the  diet  is  to  be  con- 
tinued for  at  least  a  month  before  resumption  of  a  more 
varied  menu,  though  the  quantity  given  at  one  time  may  be 
gradually  enlarged,  so  that  the  patient  is  allowed  three  larger 
and  two  smaller  meals  a  day.  Eating  at  night  is  not  advis- 
able. For  at  least  six  months  red  meat,  scratchy  articles  of 
food,  raw  fruit  and  fruit  juices,  ice  cream,  ice  water,  and  all 
highly  seasoned  articles  of  food  must  be  avoided.  Smoking 
may  be  allowed  in  moderation,  after  eating  only.  Tea  is 
not  good,  and  only  weak  coffee  and  a  small  amount  should 
be  allowed.  No  alcoholic  beverages  of  any  kind  are 
permissible,  and  the  patient  would  be  better  with  total  and 
permanent  abstinence  from  them. 

Medical  Treatment. — ^This  may  be  both  routine  and 
symptomatic,  the  former  intended  to  promote  healing  of 
the  ulcer,  the  latter  to  meet  conditions  as  they  arise. 

Many  clinicians  use  Carlsbad  water,  either  hot  or  luke- 
warm, daily  in  order  to  keep  the  bowels  gently  moving. 
Should  the  original  water  be  unavailable,  the  desiccated 
salts  may  be  obtained,  and  artificial  water  prepared.  This 
water  seems  to  both  reduce  hyperacidity  and  hypersecre- 
tion. It  is,  therefore,  of  less  use  in  ulcers  accompanied  by 
diminished  secretion. 

The  two  remedies  par  excellence  in  the  routine  treatment 
of  gastric  ulcer  are  nitrate  of  silver  and  bismuth. 

The  nitrate  of  silver  may  be  administered  in  doses  of 
1/4  to  1/2  grain  three  times  daily  for  about  four  days, 
unless  it  causes  diarrhea,  in  which  event  it  should  be  dis- 
continued for  about  two  days.  It  has  been  my  custom  to 
give  this  drug  for  four  days,  leave  it  off  for  two  days,  use 


TREATMENT    OF    ULCER  453 

it  again  for  four  days,  and  in  this  manner  to  keep  it  up  for 
about  thirty  days. 

Lavage  with  a  1:3000  solution  of  nitrate  of  silver  is 
recommended  by  some.  In  this  I  do  not  concur,  as  I 
think  it  best  to  avoid,  if  possible,  the  use  of  the  stomach- 
tube  for  fear  of  its  possible  traumatic  effect. 

Bismuth  may  be  employed  both  for  its  alkaline  and 
mechanic  effect.  Lockwood  objects  to  the  subnitrate,  as 
he  believes  the  sharp  crystals  of  this  preparation  may  irritate 
the  floor  of  the  ulcer.  I  am  not  sure  he  is  justified  in  this 
fear.  Aaron  has  written  a  valuable  paper  on  the  use  of 
bismuth  subnitrate  for  ulcer,  and  believes  that  owing  to  its 
physical  consistence,  its  fine  distribution,  and  its  high 
specific  gravity,  this  drug  is  capable  of  forming  a  layer  over 
the  ulcer,  which  mechanically  protects  it  from  injury. 
Moreover  the  good  effect  may  be  also  due  to  chemic  action, 
for  it  has  been  found  that  bismuth,  when  introduced  into 
the  stomach,  induced  a  mucous  secretion,  and  that  the 
protective  layer  was  a  muco-bismuth  mixture.  In  this 
process  bismuth  is  reduced  to  bismuth  oxide,  and  it  may  be 
assumed  that  this  is  the  principal  agent  in  the  formation 
of  the  bismuth  crust.  Owing  to  its  astringent  property, 
bismuth  is  capable  of  producing  a  healing  effect,  for,  as  is 
well  known,  astringents  precipitate  albumin  and  mucus, 
entering  into  combination  with  the  albumin  and  forming 
albuminates.  As  a  result  of  the  deposition  of  new,  firm 
particles  in  the  tissue  interspaces,  the  epithelial  surface  is 
smoothed,  and  the  size  of  the  blood-vessels  diminished. 
Secretion  is,  therefore,  reduced,  and  the  hyperemic  condi- 
tions and  attendant  pains  relieved;  and  the  fact,  that  mucous 
membrane  of  this  consistence  is  a  favorable  culture  ground 
for  bacteria,  supplies  another  reason  for  the  subsidence  of 
the  inflammatory  manifestations. 

According  to  Fleiner's  and  Aaron's  present  method 
about  ten  to  twenty  grams  of  bismuth  subnitrate  in  a 
tumbler  of  warm  water  are  taken  by  mouth  in  the  morning 
on  an  empty  stomach,  the  stomach  having  been  previously 


454  HEMATEMESIS— ULCER   OF    THE    STOMACH 

cleansed  with  about  150  c.c.  of  Carlsbad  or  Vichy  water. 
This  should  be  given  daily,  the  dose  being  increased, 
reduced,  or  discontinued,  according  to  the  clinical  course. 

A  modification  of  this  method  consists  in  administering 
bismuth  in  oil,  by  combining  the  bismuth  treatment  with 
Cohnheim's  oil  treatment,  the  doses  of  bismuth  finely 
suspended  in  olive  oil  being  taken  several  times  daily. 

When  there  is  constipation  following  the  bismuth,  or 
where  there  appears  to  be  an  idiosyncrasy  against  it,  other 
alkalies  may  be  given  to  correct  hyperacidity.  Among 
these  are  magnesia  usta,  or  magnesia  carbonate.  Soda 
bicarbonate  is  not  desirable  on  account  of  the  liberated 
carbon  dioxid  following  its  use. 

Atropin  is  of  service  to  control  pain,  to  reduce  acidity, 
and  to  relax  muscular  spasm.  It  is  chiefly  indicated  during 
attacks  of  acute  hypersecretion  from  pyloric  spasm. 

Hemorrhage  has  in  the  main  been  considered,  but  I 
might  say  that  the  drug  of  greatest  benefit  is  adrenalin 
in  lo-minim  doses  of  the  1:1000  solution.  This  may  be 
given  every  fifteen  minutes  to  half  hour,  diluted  in  a  little 
water,  until  satisfactory  results  are  attained.  Some  fear 
the  reaction  dilatation  following  the  vasomotor  constric- 
tion, but  before  this  occurs  a  thrombus  is  generally  formed 
at  the  bleeding  point.  Gelatin  and  calcium  chlorid  and 
lactate  have  been  discussed.  Ergotin  hypodermically  has 
gone  out  of  use. 

Vomiting  is  usually  relieved  by  regulation  of  diet, 
counterirritation  over  the  epigastrium,  minim  doses  of 
Fowler's  solution  or  wine  of  ipecac,  i  or  2 -minim  doses  of 
dilute  hydrocyanic  acid,  or  1/2-grain  doses  of  menthol. 
Oxalate  of  cerium  has  not  proved  satisfactory,  though  I 
have  gotten  some  results  from  chloretone  in  3 -grain 
doses. 

Pain  should  be  controlled  by  heat,  alkalies,  atropin,  or 
abstinence  from  food.  Should  pain  keep  up  for  over  ten 
days  after  a  systematic  ulcer  treatment,  there  is  probably 
some  complication  which  requires  appropriate  attention. 


TREATMENT   OF   ULCER  455 

Perforation  is  a  surgical  complication,  and  dalliance  with 
any  other  measures  may  lose  for  the  patient  his  chance  of 
recovery.  Cases  of  spontaneous  cure  which  have  been  re- 
ported do  not  afford  any  excuse  for  a  waiting  or  expectant 
course. 

For  the  anemia  and  debility  Blaud's  mass  or  pill  is  prob- 
ably the  best  ferruginous  preparation.  None  of  the  iron 
preparations  containing  alcohol  as  a  menstruum  should  be 
given.  Should  the  stomach  be  intolerant  of  any  form  of 
iron,  the  hyperdermic  injections  of  the  green  citrate  of  iron 
may  be  administered.  This  can  now  be  obtained  in 
ampules,  and  is  a  convenient  form  for  use. 

Einhorn's  Duodenal  Method  in  Gastric  Ulcer. — In  this 
method  Einhorn  gets  the  duodenal  tube  in  situ,  as  pre- 
viously described,  and  feeds  the  patient  directly  into  the 
small  intestine  for  two  weeks.  The  dietary  and  the 
methods  of  introduction  have  been  described  in  a  previous 
chapter. 

During  the  time  of  the  duodenal  alimentation  full  doses 
of  bismuth  should  be  swallowed  each  day,  or  occasional 
doses  of  magnesia  usta,  when  it  is  desired  to  temporarily 
discontinue  the  bismuth.  The  mouth  should  be  kept 
well  cleansed  with  an  aromatic  alkali,  as  liquor  alkaline 
antiseptic. 

In  proper  cases  this  method  is  invaluable,  and  yields 
splendid  results.  Where,  however,  it  seems  that  the  tube 
impinges  upon  the  ulcerated  or  inflamed  area,  the  patient 
can  get  no  peace  nor  comfort  until  the  tube  is  removed. 
Occasionally,  when  the  stomach  seems  intolerant  of  the 
tube,  if  it  is  removed  and  rectal  feeding  resorted  to  for 
forty-eight  hours,  it  can  be  replaced  and  comfortably 
retained. 

After  fourteen  days  of  this  feeding  have  passed,  the  tube 
should  be  removed,  and  the  combined  Leube-Ziemssen 
method  of  feeding  inaugurated  with  rather  rapid  increase. 

There  are  attractive  possibilities  in  this  method  of  ulcer 
treatment,  and  with  proper  technic  it  will  probably  yield 


456  HEMATEMESIS — ULCER   OP    THE    STOMACH 

tangible  healing  results  without  weakening  the  patient  as 
do  some  of  the  other  plans. 

Therapeutic  Use  of  the  X-rays. — This  has  been  advocated 
by  Bassler,  who  argues  that  from  the  beneficial  effects  ob- 
tained in  the  treatment  of  cutaneous  ulcers  of  all  types  and 
its  discutient  effect  on  cicatricial  conditions,  such  as  may 
be  seen  in  scars  of  furunculosis  of  the  neck,  cicatrices  from 
injuries,  etc.,  that  ulcers  of  the  stomach  might  likewise  be 
favorably  influenced  by  the  X-rays.  While  he  has  re- 
ported some'  apparently  favorable  results,  the  dangers 
incident  to  exposure  to  the  rays  have  deterred  many  from 
attempting  this  method,  and  it  will  not  probably  come  into 
much  use. 

INDICATIONS  FOR  SURGERY 

If  any  of  the  following  complications  arise  during  the 
course  or  medical  treatment  of  gastric  ulcer,  surgery 
should  be  advised,  the  time  for  such  attack  depending  on 
the  urgency  of  the  symptoms : 

Perforation  with  commencing  peritonitis;  local  peritoni- 
tis, with  or  without  abscess,  subphrenic  abscess,  peri- 
gastric adhesions,  decided  ectasia  due  to  stenosis  from  ulcer 
or  spasm  from  its  irritation,  or  gastric  tetany  with  ulcer. 
In  recurrent  acute  hemorrhages  it  may  be  necessary  to  enter 
the  stomach,  locate  the  bleeding  point,  and  suture  it.  In 
cases  of  chronic  ulcer,  with  recurrent  hemorrhages,  after 
systematic  treatment  for  eight  months  to  a  year,  if  the 
patient  is  still  complaining  and  apparently  losing  ground, 
surgery  may  be  favorably  considered,  though  some  surgeons 
hesitate  to  operate  unless  there  is  pyloric  stenosis.  The 
present  trend  is  toward  quicker  resort  to  surgery  in  gastric 
ulcers,  especially  since  the  technic  has  been  so  improved. 

In  cases  of  pyloric  obstruction  from  ulcer  with  dilatation 
of  the  stomach,  though  medical  treatment  may  show  a 
temporary  improvement,  surgery  really  offers  the  only 
permanent  relief. 


CHRONIC   EROSIONS  457 

Excision  of  the  ulcer  in  chronic  cases  will  probably 
prevent  in  many  instances  the  development  of  cancer  in 
later  life,  as  the  liability  of  cancer  to  develop  upon  the  site 
of  a  healed  ulcer  is  well  known.  Some  observers  claim  that 
at  least  75  per  cent,  of  cancers  have  their  origin  in  chronic 
gastric  ulcer,  while  Wilson  and  McCarthy,  writing  from  the 
Mayo  clinic,  report  that  of  153  specimens  of  undoubted 
carcinoma  taken  from  the  stomach  at  time  of  operation, 
71  per  cent,  "presented  sufficient  gross  and  microscopical 
evidence  of  previous  ulcer  to  warrant  placing  them  in  a 
group  labeled  'carcinoma  developing  from  previous  ulcer.' 
Eleven  other  cases  showed  considerable  evidence  of  pre- 
cendent  ulcer,  but  not  sufficient  to  warrant  placing  them  in 
the  previous  group.  In  33  cases  (22  per  cent.)  there  was 
relatively  small  or  no  pathological  evidence  of  precedent 
ulcer."  Though  the  Mayo  clinic  receives,  as  a  rule,  only 
the  chronic  ulcers  which  have  resisted  all  forms  of  medical 
treatment,  these  figures  afford  food  for  reflection,  and  show 
the  possible  future  danger  of  allowing  an  ulcer  to  remain  in 
painful  evidence  for  months  or  years. 

CHRONIC  EROSIONS 

These  may  be  chronic  or  acute,  and  may  be  properly 
discussed  in  this  chapter. 

Acute  erosions  are  small  abrasions  of  the  mucosa  of  the 
stomach,  generally  multiple,  and  extending  partly  through 
the  layer.  There  is  frequent  hemorrhage  with  this  type, 
which  may  occur  in  the  new-born,  in  the  cachexia  of  children, 
in  chronic  heart  and  arterial  disease,  in  cirrhosis  of  the  liver, 
in  some  post-operative  cases,  and  sometimes  is  associated 
with  the  throbbing  aorta  in  neurotic  women.  Erosions 
seem  to  be  rather  frequently  manifested  among  hard 
drinkers,  especially  middle-aged  men  with  livers  somewhat 
cirrhosed.  In  such  cases  the  hemorrhage  seems,  to  an 
extent,  to  be  compensatory  and  beneficial. 

The  treatment  is  naturally  that  of  the  cause  of  these 


458  HEMATEMESIS — ULCER   OF   THE    STOMACH 

erosions,  as  mentioned  above,  and  the  treatment  of  the 
attendant  hematemesis  the  same  as  in  gastric  hemorrhage 
from  other  pathologic  conditions.  Occasionally  these 
erosions  are  so  numerous  that  the  hemorrhage  is  fatal. 
George  H.  Noble  reports  a  case,  in  which  after  repeated 
hemorrhages,  he  entered  the  stomach,  but  found  blood 
oozing  from  practically  the  whole  gastric  surface,  and 
which  could  not  be  stopped. 

Chronic  erosions  are  small  superficial  exfoliations  of  the 
gastric  mucosa,  and  it  is  claimed  by  some  that  they  present 
a  part  of  the  clinical  picture  of  chronic  gastritis.  Einhorn 
first  described  this  condition  as  a  clinical  entity. 

Diagnosis. — This  consists  of  pain,  emaciation,  weakness, 
and  lassitude,  and  finding  in  the  wash-water  after  lavage 
one  or  more  small  pieces  of  gastric  mucous  membrane. 
There  is  usually  a  decrease  in  acidity  and  free  hydrochloric 
acid  and  considerable  mucus.  Einhorn  believes  that  the 
"erosions"  resulting  from  the  peeling  off  of  the  mucous 
membrane  are  responsible  for  the  pain  and  tenderness,  and 
that  it  has  not  yet  been  determined  whether  the  exfoliation 
recurs  at  the  same  place  after  healing  or  in  new  regions  of 
the  stomach. 

The  disease  is  usually  of  long  duration  with,  at  times, 
intervals  of  improvement. 

Treatment. — This  depends  upon  the  gastric  findings, 
being  much  the  same  as  in  chronic  gastritis.  Hyperacidity, 
hypoacidity,  or  achylia  require  appropriate  consideration. 

There  are  three  methods  of  local  treatment  advocated: 

(i)  Lavage  every  other  day  with  an  alkaline  wash  to 
dissolve  the  mucus,  and  15  to  30  grains  of  bismuth  before 
each  meal,  taken  in  a  half -glass  of  water. 

(2)  The  administration  of  nitrate  of  silver  as  in  ulcer  of 
the  stomach  is  probably  the  best  method  of  treating  chronic 
erosions.  Lavage  also  is  useful,  and  the  stomach  may  first 
be  cleansed  with  a  warm  alkaline  solution  and  then  washed 
with  the  nitrate  of  silver  solution,  i :  1000  or  i  .2000. 

Einhorn  advocates  intragastric  galvanization  one  day, 


TREATMENT   OP   EROSIONS  459 

with  nitrate  of  silver  spray  preceded  by  lavage  on  the 
following  day,  and  so  alternating. 

(3)  The  extract  of  the  suprarenal  gland  has  been  also 
recommended.  It  may  be  used  in  the  Einhorn  powder- 
blower,  and  applied  to  the  stomach  every  other  day,  3 
grains  at  a  time.  This  method  has  apparently  given  some 
good  results. 

Measures  for  the  upbuilding  of  the  body,  the  strengthen- 
ing of  the  nervous  system,  and  the  improvement  of  general 
tone,  are  all  helpful  in  healing  gastric  erosions. 


CHAPTER  XIX 

TUMORS  OF  THE  STOMACH— FOREIGN  BODIES  IN 
THE  STOMACH 

In  an  analysis  of  30,000  cases  of  cancer,  W.  H.  Welch 
finds  the  stomach  involved  in  21.4  per  cent.,  standing  next 
in  frequency  to  uterine  cancer.  Osier,  Haberlin,  Brinton, 
Virchow  and  other  have  placed  the  frequency  of  cancer  of 
the  stomach  at  from  15  to  35  per  cent.,  while  all  agree  as  to 
its  alarming  prevalence. 

Race. — It  has  been  supposed  that  some  races  were  less 
susceptible  than  others.  Negroes  seem  to  suffer  less  than 
whites,  and  it  has  been  seldom  observed  in  Egypt  and  some 
parts  of  South  America.  Kuttner  has  commented  on  the 
prevalence  of  cancer  in  southeastern  Germany,  and  Bryant 
claims  that  it  is  on  the  increase  in  the  United  States.  It 
has  been  noted  in  recent  years  that  in  countries  where  this 
disease  was  supposed  to  be  rare,  that  upon  the  establish- 
ment of  a  proper  system  of  vital  statistics,  it  would  be 
found  in  abundance. 

Age. — Welch  finds  that  three-fourths  of  the  cases  in  his 
analysis  occurred  between  the  ages  of  forty  and  seventy, 
with  the  majority  between  forty  and  sixty.  Cases  tinder 
thirty  are  rare  indeed,  though  J.  L.  Campbell  has  just  re- 
ported to  me  personally  a  case  that  came  to  operation  in  a 
girl  of  fourteen. 

Sex. — Welch  finds  cancer  of  the  stomach  slightly  more 
frequent  among  men  than  women,  and  Osier  in  150  cases, 
finds  126  males  and  24  females. 

Heredity. — Most  of  the  recent  statistics  have  tended  to 
disprove  the  heredity  of  cancer,  though,  on  the  whole,  this 
question  is  still  undecided. 

460 


VARIETIES    OF    CANCER  46 1 

Traumatism. — This  has  been  given  by  some  as  a  promi- 
nent factor  in  etiology,  but  Osier  reports  only  one  case  in  his 
series.  Deaver  refers  to  the  influence  of  trauma,  citing  as 
an  example  skin  carcinoma  caused  by  continued  exposure  to 
the  X-ray. 

Chronic  inflammatory  disease  of  the  mucous  membrane 
of  the  stomach  is  considered  a  predisposing  factor  by  some 
in  the  production  of  carcinoma,  especially  the  polypoid 
form  of  gastritis.  As  a  rule,  however,  carcinoma  develops 
without  previous  history  of  long-standing  gastric  disturb- 
ance, and  Ewald  and  Einhorn  are  probably  correct  in  the 
assumption  that  these  conditions  have  little  or  no  influence. 

The  development  of  cancer  upon  an  ulcer  scar  has  been 
clinically  demonstrated  many  times,  and  it  is  now  thought 
that  about  71  per  cent,  develop  from  that  cause.  When 
one  remembers  that  in  about  5  per  cent,  of  persons  dying 
from  all  causes  Brinton  finds  evidences  of  gastric  ulcer,  it 
can  be  understood  how  carcinoma  can  develop  on  an  ulcer 
with  no  apparent  previous  gastric  symptoms. 

The  parasitic  origin  of  cancer  is  being  strenuously  investi- 
gated, but  has  not  as  yet  been  proved. 

Varieties. — The  most  common  form  are  the  cylindrical- 
celled  adenocarcinoma  and  the  encephaloid  or  medullary 
carcinoma;  next  in  frequency  is  the  scirrhus;  and  least 
frequent  is  the  colloid  cancer. 

Adenocarcinoma.- — This  type  forms  soft  tumors  of  firmer 
consistency  than  the  medullary  type,  and  sloughing  slowly. 
Microscopically,  a  section  shows  elongated  tubular  spaces 
filled  with  columnar  epithelium,  while  the  intervening 
stroma  is  abundant.  Gradually  the  tubular  spaces  de- 
velop into  cell  nests,  there  is  frequent  infiltration  of  the 
connective  tissue  with  white  blood  corpuscles,  and  cystic 
degeneration  is  common. 

Medullary  Carcinoma.- — This  occurs  in  soft,  spongy, 
fungating  masses,  which  involve  all  the  coats  of  the 
stomach,  usually  ulcerating  early.  It  is  large,  often  flat, 
projecting  above  the  mucous  membrane,  and  may  form  a 


462  TUMORS    or   THE    STOMACH 

cauliflower-like  outgrowth.  It  is  soft  and  grayish  or  yel- 
lowish white  in  color.  Microscopically,  it  shows  scanty 
stroma,  enclosing  alveoli  containing  irregular  polyhedral 
and  cylindric  cells.  This  form  also  shows  a  tendency  to 
ulcerate,  and  metastases  are  frequent. 

Scirrhous  Carcinoma. — This  type  is  characterized  by 
great  hardness,  due  to  abundance  of  stroma  and  limited 
amount  of  alveolar  structure.  The  large  amount  of  con- 
nective tissue  makes  the  tumor  firm  and  compact.  There  is 
only  slight  tendency  to  ulcerate,  except  at  a  late  stage 
superficially,  and  secondary  metastases  are  not  common. 
This  form  is  rather  often  seen  at  the  pylorus,  though  at 
times  it  may  be  diffuse,  involving  all  parts  of  the  stomach. 
It  has  been  reported  in  the  stomach  as  secondary  to  uterine 
cancer,  and  it  may  be  combined  with  the  medullary  type. 

Colloid  Carcinoma. — This  form  is  characteristic  from  the 
fact  that  it  invades  widely  all  the  coats  of  the  stomg-ch, 
frequently  spreading  to  the  neighboring  parts  and  causing 
secondary  growths  of  the  same  nature  in  other  organs. 

Its  appearance  is  distinctive,  showing  large  alveoli  filled 
with  translucent  gelatinous  material,  colloid  in  nature.  On 
scraping  no  cancer  juice  exhudes,  but  gelatinous  fragments. 

Sarcoma. — This  may  be  primary  or  secondary,  and  is  a 
neoplasm  consisting  of  small  cells  of  an  adenoid  or  embryonic 
type  without  epithelial  appearance  and  in  many  cases 
without  stroma.  Primary  gastric  sarcoma  occurs  in  two 
forms — infiltrated  and  circumscribed.  The  usual  location 
of  starting  point  of  lymphosarcoma  is  the  pylorus,  and  this 
variety  may  infiltrate  the  entire  wall  of  the  stomach  with- 
out invading  the  orifices.  Next  in  frequency  is  the  myosar- 
coma, having  its  starting  point  in  the  muscular  coat.  This 
form  and  the  fibrosarcoma  often  acquire  enormous  size, 
with  frequent  metastases.  Many  cases  of  gastric  sarcoma 
cannot  be  distinguished  clinically  from  gastric  carcinoma, 
especially  in  the  round-celled  type,  in  the  course  of  which 
ulcerations,  softening  and  hemorrhage  may  occur,  with 
occasional  perforations. 


DIAGNOSIS    OF   CANCER   OF    STOMACH  463 

Unlike  carcinoma,  sarcoma  is  often  a  disease  of  young 
adults,  although  certain  forms  of  sarcoma  seem  to  be  most 
common  in  the  old.  Sex  does  not  show  any  particular 
difference  as  to  the  frequency  of  its  occurrence,  nor  has  a 
parasitic  origin  been  demonstrated.  Cohnheim's  theory 
pertaining  to  the  origin  of  cancer  seems  to  bear  a  greater 
significance  in  sarcoma,  for  the  reason  that  the  latter  growths 
are  so  closely  related  to  undeveloped  connective  tissue  that 
sarcomatous  tissue  may  be  compared  to  embryonal  tissue. 

Softening,  hemorrhage  and  perforation  occur  but  seldom 
in  gastric  sarcoma,  owing  to  the  fact  that  it  is  an  infiltrating 
growth  with  neither  contraction  nor  obstruction.  If  the 
latter  occurs,  it  is  due  more  to  mechanical  conditions  than 
to  a  constriction  of  the  growth. 

Diagnosis. — The  course  of  sarcoma  of  the  stomach  is 
variable.  In  some  a  long  dyspeptic  history  may  be  ob- 
tained, while  in  others  symptoms  did  not  appear  until  an 
easy  palpation  of  the  tumor  was  possible.  Cachexia,  as  a 
rule,  appears  late,  and  as  stenosis  is  seldom  present,  emesis 
may  be  lacking  through  the  whole  course  of  the  sarcoma. 
Pains  in  the  epigastrium  and  vicinity  may  appear  early 
and  be  intense.  Free  hydrochloric  acid  is  absent  gener- 
ally, and  lactic  acid  present.  Boas-Oppler  bacilli  are 
occasionally  found.  Marked  anemia  is  developed  as  the 
disease  progresses,  and  death  may  occasionally  take  place 
from  hemorrhage. 

The  following  differential  points  as  between  gastric 
carcinoma  and  sarcoma  have  been  collated  by  Aaron: 

Carcinoma.  Sarcoma. 

(i)  Much  pain.  Much  pain  early,  which  diminishes 

as  the  tumor  becomes  palpable. 
Sometimes  no  pain  at  all. 

(2)  Involvement  of  the  orifices.  Orifices  not  involved  or  rarely  so. 

(3)  Stenosis  marked.  Stenosis  seldom. 

(4)  Hemorrhage  early.  Hemorrhage  late  in  the  disease. 

(5)  Markedly  malignant.  Less  malignant  in  its  course. 

(6)  Growth  rapid.  Growth  comparatively  slow. 

(7)  Metastases  early.  Metastases  late. 

(8)  Cachexia  early.  Cachexia  late. 


464  TUMORS    OF    THE    STOMACH 

Benign  Tumors  of  the  Stomach. — These  are  extremely 
rare,  seldom  producing  any  symptoms  during  life,  though 
they  may  occasionally  ulcerate,  causing  hemorrhage  and 
perhaps  later  on,  obstruction.  These  growths  may  be 
simple  or  multiple,  sessile  or  pedunculated,  and  are 
classified  according  to  the  tissues  or  gastric  layers  from 
which  they  are  derived,  as  lipomata  or  fatty  tumors  arising 
from  the  sub-mucosa  of  any  part  of  the  gastric  walls ;  fibro- 
mata, probably  arising  from  fibrous  thickenings  of  the 
pylorus  or  elsewhere  in  the  stomach,  arising  from  old 
cicatrizing  ulcers;  fibromyomata,  or  benign  tumors  which 
project  into  the  stomach,  and  consist  of  unstriped  muscle 
fibers  in  fibrous  tissue. 

Cysts  may  be  formed  in  the  stomach  by  the  occlusion  of 
ducts  of  gastric  glands.  These  may  attain  the  size  of  a 
small  walnut,  but  they  are  usually  quite  small  and  multiple, 
having  the  appearance  of  minute  vesicles. 

Epigastric  Hernia. — This  condition  is  brought  about  by  a 
rupture  occurring  at  some  part  of  the  linea  alba  between  the 
umbilicus  and  ensiform  process.  It  is  classed  among  the 
preperitoneal  lipomata,  being  made  up  of  omentum  and  fat, 
and  varies  in  size  from  a  bean  to  an  egg.  Careful  palpation 
is  generally  required  to  diagnose  this  tumor. 

The  symptoms  produced  by  the  presence  of  an  epigastric 
hernia  may  stimulate  almost  any  gastric  disorder,  and  has 
been  mistaken  for  gastric  ulcer,  acute  or  chronic  gastritis, 
gastralgia,  carcinoma,  and  cholelithiasis. 

Treatment.- — This  is  surgical,  other  methods  being  a 
waste  of  time  and  effort. 

DIAGNOSIS  OF  CANCER  OF  THE  STOMACH 

An  early  diagnosis  of  this  disease,  with  an  early  recourse 
to  surgery  offers  a  fair  chance  for  permanent  recovery.  A 
sad  feature  of  gastric  cancer  is  the  fact  that  after  the 
growth  has  advanced  to  such  a  stage  that  diagnosis  is 
plain  and  easy,  treatment  is  often  either  unavailing,  or 


DIAGNOSIS    OF    CANCER    OF    THE    STOMACH  465 

surgical  procedures  are  out  of  the  question.  It  is,  therefore, 
of  the  utmost  importance  that  every  diagnostic  method  be 
brought  to  bear  upon  a  suspected  case,  in  order  that  speedy 
and  radical  measures  may  be  inaugurated,  should  cancer  be 
found. 

General  Symptoms. — Usually  a  patient  of  middle  age, 
previously  in  good  health  perhaps  up  to  six  or  less  months 
before  consulting  the  physician,  comes  complaining  of 
dyspeptic  disturbances,  loss  of  appetite,  fulness,  pressure 
and  discomfort  after  eating.  The  previous  history  of  good 
health,  however,  will  nearly  always  be  slightly  modified  after 
careful  cross  examination,  for  practically  all  will  admit 
periodical,  though  perhaps  slight,  attacks  of  indigestion 
in  former  years,  pointing  in  many  instances  to  gastric 
ulcer.  The  feeling  of  discomfort  and  ill-being  later  on 
merges  into  pain,  generally  not  of  the  spasmodic  type  noted 
in  ulcer,  but  continuous  in  character.  The  pain  is  some- 
times increased  by  food,  but  is  often  intense  at  a  later  period 
of  digestion  than  in  ulcer.  With  belching  there  is  at  first 
regurgitation  of  food,  later  vomiting,  not  after  every  meal, 
but  once  or  twice  daily.  This  vomiting  is  naturally  more 
prominent  when  the  growth  sets  up  a  stenosis  of  the 
pylorus. 

As  the  cancer  progresses,  there  is  generally  hematemesis 
several  times  in  succession,  the  vomitus  being  of  a  coffee- 
ground  appearance  and  not  large  in  quantity.  The  patient 
has  during  this  time  been  losing  flesh  and  strength,  and 
perhaps  cachexia  is  now  apparent.  As  the  disease 
progresses,  weakness  and  prostration  become  more  and 
more  marked,  and  he  finally  dies  of  inanition  or  of  complica- 
tions. 

A  brief  analysis  of  the  symptoms  is  in  order. 

Anorexia.^ — This  occurs  in  about  85  per  cent,  of  all  cases, 
and  as  a  rule  is  progressive.  Many  patients  find  that 
meat  is  especially  repugnant  to  them,  and  hyperkoria  or 
increased  sense  of  satiety,  is  noticeable.  It  is  probable 
that  progressing  toxemia  is  responsible  for  the  anorexia. 
30 


466  TUMORS    or    THE    STOMACH 

Pain. — Actual  and  acute  pain  may  not  be  prominent  in  all 
cases,  but  it  is  doubtful  if  any  progress  to  a  fatal  termina- 
tion without  a  certain  amount  of  local  discomfort  being 
complained  of  at  some  time  during  its  course.  Osier  reports 
pain  in  130  out  of  150  cases,  and  Brinton  finds  it  in  92  per 
cent,  of  his  cases.  Lockwood's  private  patients  showed 
15  per  cent,  in  which  no  pain  appeared. 

When  pain  is  present,  however,  it  is  generally  a  promi- 
nent symptom,  and,  while  not  intense,  it  is  constant  and 
wearing  in  its  character.  It  is  usually  noted  at  an  early 
date,  first  in  the  epigastrium,  but  may  be  referred  to  the 
hypochondriac  regions,  the  sternum,  the  shoulders  or  back. 
This  pain,  unlike  ulcer,  is  not  generally  relieved  at  the  end 
of  gastric  digestion.  Sometimes  over  the  region  of  the 
tumor  the  pain  is  most  intense,  at  other  times  it  is  described 
as  a  painful  dull  feeling.  Cancers  of  the  cardia  are  often 
characterized  by  pain  during  or  after  swallowing.  An  im- 
portant point  in  the  consideration  of  cancer  pain  lies  in  the 
fact  that  it  is  not  so  amenable  to  bland  or  liquid  diet  as 
ulcer.  A  patient  who  is  carefully  dieted  for  a  week  or 
more,  and  who  admits  no  amelioration  of  the  pain  may  well 
be  viewed  with  suspicion  of  possessing  malignant  trouble. 

Vomiting. — This  occurred  in  128  out  of  the  150  cases 
reported  by  Osier,  and  in  87  per  cent,  of  Brinton's  cases.  At 
first  it  is  not  very  frequent  but  later  on  may  occur  several 
times  daily.  It  is  more  frequent  when  the  pylorus  is  in- 
volved, and  may  come  on  only  at  stated  intervals,  the  vom- 
itus  containing  mucus,  undigested  food,  changed  blood,  and 
Boas-Oppler  bacilli.  Sarcinse  rarely  are  present,  being 
noted  more  often  in  benign  stenosis.  A  few  cases  have  been 
noted  in  which  extensive  involvement  of  the  anterior  or 
posterior  wall  of  the  stomach  was  accompanied  by  no 
vomiting. 

Hemorrhage. — This  occurred  in  36  of  Osier's  150  cases, 
and  Brinton  places  it  at  42  per  cent.  The  blood  is  usually 
visible,  is  mixed  with  the  secretions  of  the  stomach,  is  dark 
in  color,  and  rarely  a  bright  red ;  also  less  in  quantity  than 


DIAGNOSIS    OF    CANCER    OF    THE    STOMACH  467 

in  ulcer.  Fatal  hemorrhage  in  carcinoma  of  the  stomach  is 
rare  indeed. 

Loss  of  Weight  and  Cachexia.^ — These  show  in  practically 
every  case.  Sometimes  in  the  early  stages  of  a  carcinoma, 
if  special  efforts  toward  keeping  up  the  nutrition  are 
exerted,  a  patient  may  look  well  and  keep  up  his  weight, 
but  this  cannot  last  long,  and  the  inevitable  emaciation 
appears  later  on  with  seemingly  greater  rapidity.  With 
the  emaciation  comes  the  sallow  skin  with  its  peculiar 
ashy  look,  and  loss  of  strength  and  weight  presage  with 
realistic  certainty  the   termination. 

The  Blood. — Anemia  is  nearly  always  present,  though 
occasionally  when  there  is  copious  vomiting  with  but  little 
ingestion  of  fluids,  the  blood  may  become  concentrated  and 
show  normal  or  increased  red  cells  with  high  hemoglobin. 
This  is  only  temporary,  though  the  count  is  sometimes 
surprisingly  high  considering  the  cachexia.  Leucocytosis  is 
present  in  gastric  cancer,  usually  mild,  and  rarely  above 
12,000  to  15,000.  In  occasional  cases  the  blood  count  is 
so  low  as  to  suggest  pernicious  anemia,  but  the  absence 
of  megaloblasts  and  the  presence  of  leucocytes  suggest 
cancer. 

Tumor. — In  connection  with  other  diagnostic  points  the 
presence  of  a  palpable  tumor  in  the  epigastrium  is  almost 
pathognomonic. 

Inspection. — But  little  can  be  gained  from  this  except 
in  rather  advanced  cases.  In  a  good  light  there  may  some- 
times be  observed  a  fulness  under  the  left  costal  arch  or^a 
localized  fulness  or  prominence  in  the  epigastrium  showing 
respiratory  movements.  This  prominence  may  be  due  to 
the  growth  itself,  or  in  the  presence  of  pyloric  stenosis,  to  a 
distended  stomach. 

Peristaltic  movements  are  often  noted  when  stenosis  is 
marked,  and  in  decided  gastroptosis  the  lesser  curvature 
may  be  seen  at  times  with  the  tumor  moving  with  respira- 
tion. Inspection  with  the  patient  standing,  as  suggested 
by  Knapp,  will  frequently  yield  additional  information. 


468  TUMORS    OF    THE    STOMACH 

Percussion. — This  may  or  may  not  be  of  assistance, 
though  the  auscultatory  or  scratching  method  of  percussion 
may  in  some  instances  give  a  dull  note  over  the  tumor. 

Palpation. — This  is  reliable  if  the  patient  is  not  too 
stout  or  if  the  tumor  has  advanced  to  the  stage  where  it 
can  be  felt.  The  location  of  the  tumor  makes  quite  a  dif- 
ference, for,  if  located  on  the  posterior  wall  of  the  stomach, 
it  is  hard  to  recognize,  unless  the  stomach  is  empty.  When 
the  tumor  is  on  the  lesser  curvature  and  the  stomach  in 
normal  position,  it  cannot  be  palpated  except  on  deep 
inspiration. 

Another  point  of  much  moment  in  considering  surgery  is 
the  fact  that  gastric  tumors  seem  smaller  to  the  palpating 
finger  than  they  appear  at  operation. 

Inflation. — This  is  of  some  value  in  deciding  whether  the 
growth  is  connected  with  the  stomach.  If  during  inflation 
the  tumor  moves  away  from  the  liver,  the  diagnosis  of 
tumor  of  the  stomach  may  be  made  and  that  of  the  liver  or 
gall-bladder  excluded.  Should  this  not  occur,  there  may 
be  adhesions  or  involvement  of  both  organs.  A  tumor  of 
the  pylorus  generally  moves  to  the  right  and  downward  on 
inflation.  Tumors  of  the  posterior  wall  and  lesser  curvature 
that  are  palpable  before  inflation,  are  frequently  so  no 
longer  after  the  stomach  is  filled  with  air  or  gas.  It  is  well 
to  first  map  out  the  position  of  the  stomach  before  infiation, 
and  to  mark  the  boundaries  with  a  pencil.  After  inflation 
this  can  be  repeated  and  the  data  obtained  can  be  better 
understood. 

A  great  amount  of  inflation  in  a  stomach  whose  walls  are 
weakened  entails  a  risk. 

Transillumination. — This  method,  as  described  in  a 
previous  chapter,  may  be  of  some  service,  when  the  tumor  is 
on  the  anterior  wall  of  the  stomach,  or  the  shape  of  the 
stomach  has  been  changed  by  its  presence ;  otherwise  not 
much  information  can  be  gained. 

Esophagoscopy. — This  method  applied  only  to  tumors 
situated  in   the   cardiac   orifice,   and  the  passage   of  the 


DIAGNOSIS    OF   CANCER   OF   THE    STOMACH  469 

esophagoscope  would  probably  cause  more  damage  than  the 
information  obtained  would  profit  the  patient  or  physician. 

Gastroscopy. — In  the  Journal  of  the  A.  M.  A.,  Oct.  ii, 
1913,  there  appears  an  article  by  Dr.  H.  H.  Janeway,  in 
which  he  enthusiastically  advocates  this  method  for  early 
diagnosis  of  cancer  of  the  stomach.  In  the  course  of  his 
article  he  says  ' '  Up  to  the  present  time  I  have  made  a  posi- 
tive diagnosis  by  this  method  in  twenty  cases  of  cancer  of 
the  stomach,  in  two  of  which  the  roentgenoscopic  examina- 
tion was  negative."  He  further  says,  "I  am  convinced 
that,  if  proper  gentleness  and  carefulness  of  technic  are 
exerted,  it  is  possible  to  diagnose  cancer  of  the  cardia 
simply  with  the  aid  of  cocainization  of  the  pharynx  and 
without  causing  pain  or  an  amount  of  discomfort  to  which  a 
normal  person  would  object."  This  opens  up  interesting 
possibilities  which  are  as  yet,  perhaps,  in  a  nebulous  state. 

Subjective  Symptoms  Due  to  Location  of  the  Tumor. — 
If  at  or  very  near  the  cardia,  the  patient  finds  at  first  a 
slight  impediment  to  swallowing,  and  frequently  has  to 
wash  down  his  food  with  draughts  of  liquid.  Later  on  this 
increases,  and  he  finds  it  impossible  to  take  solid  food. 
If  he  tries  to  swallow,  the  food  is  regurgitated,  sometimes 
with  much  retching,  and  mixed  with  mucus  or  streaks  of 
blood.  Upon  examination  with  a  bougie  the  obstruction 
may  be  easily  felt,  and  the  location  and  size  of  the  stricture 
determined.  Force  should  not  be  exerted,  or  trauma  with 
increased  proliferation  of  the  growth  may  be  induced. 

When  the  growth  is  in  the  pyloric  region  there  is  pain, 
fulness  in  the  stomach,  and  frequent  attacks  of  vomiting. 
Sometimes  just  before  emesis  there  are  sharp  pains  caused 
by  the  efforts  of  the  stomach  to  expel  the  food  through  the 
inflamed  and  constricted  pylorus.  The  vomitus  is  gener- 
ally large  in  amount,  and  may  be  of  offensive  odor.  Peris- 
taltic unrest  with  cramping  pains  are  also  noted. 

When  the  cancer  invades  the  body  of  the  stomach, 
general  pain  is  complained  of,  vomiting  may  not  be  such  a 
prominent    symptom,    and    the    vomitus    is    more   finely 


470  TUMORS    OP   THE    STOMACH 

divided.  There  may  be  slight  motor  insufficiency,  but  this 
does  not  generally  take  place  until  cachexia  is  far  advanced. 

Chemic  Examination  of  Stomach  Contents. — An  Ewald- 
Boas  test-meal  should  be  given,  and  one  hour  later  should 
be  aspirated  carefully. 

Hydrochloric  Acid. — ^This  is  deficient  or  absent  in  a 
majority  of  cases.  Osier  found  it  absent  in  84  out  of  94 
cases  examined,  and  Boas  found  it  absent  in  35  out  of  40. 
Graham  found  in  the  Mayo  clinic,  however,  only  80  cases  of 
absent  hydrochloric  acid  in  150  cases.  The  absence  of  free 
hydrochloric  acid  is  not  pathognomonic  of  cancer,  but 
taken  in  connection  with  other  symptoms  forms  a  strong 
link  in  the  chain  of  evidence. 

Lactic  Acid.- — -This  may  be  found  in  those  cases  of  cancer 
in  which  there  is  a  stagnation  of  the  stomach  contents, 
resulting  from  pyloric  obstruction,  and  where  the  atrophy  of 
the  mucous  membrane  has  progressed  to  the  point  where 
measurable  amounts  of  free  hydrochloric  acid  are  no 
longer  secreted.  Its  presence,  therefore,  is  not  pathogno- 
monic, but  simply  shows  a  certain  amount  of  food-stasis  and 
is,  like  the  absence  of  free  hydrochloric  acid,  a  corrobora- 
tive symptom. 

Lockwood  reports  normal  chemic  findings  in  15  per  cent, 
of  his  cases. 

Macroscopic  and  Microscopic  Examination. — To  the 
eye  there  appear  undigested  food  particles,  and  perhaps 
coffee-ground  material.  The  aspirated  contents  often 
divide  into  two  layers  on  standing,  the  upper  three-fifths 
being  liquid,  the  lower  two-fifths  being  food  remains,  mucus, 
and  perhaps  pus  or  exfoliated  gastric  mucosa.  Micro- 
scopically there  can.  be  seen  pus,  amorphous  material,  blood 
corpuscles,  or  Boas-Oppler  bacilli. 

Specific  Tests  for  Gastric  Cancer.— In  1909  Neubauer 
and  Fischer  announced  that  the  cancer  ferment  had  the 
power  of  hydrolizing  simple  peptids.  One  of  the  products 
of  this  cleavage  when  the  dipeptid  glycyl-tryptophan  is  acted 
upon   is   tryptophan,    an   amino-acid,   whose  presence  in 


DIAGNOSIS    OF   CANCER   OF   THE   STOMACH  47 1 

gastric  contents  is  easily  ascertained.  The  "  glycyl-tryp- 
tophan  test,"  therefore,  depends  upon  this  reaction. 

J.  W.  Weinstein  holds  that  the  use  of  glycyl-tryptophan  is 
useless,  and  that  it  is  only  necessary  to  test  for  tryptophan 
in  the  gastric  filtrate  without  employing  the  former  at  all. 
The  presence  of  tryptophan  he  claims  is  sufficient.  He 
gives  a  regular  dinner  at  noon,  consisting  of  bread,  butter, 
meat  prepared  plainly  without  seasoning,  and  sweet  weak 
tea  without  milk.  Pepper  and  lemon  juice  interfere  with 
the  reacton.  Sugar  seems  an  excellent  stimulant  to  the 
secretion  of  the  cancer  enzyme,  and  beef  he  finds  better  than 
chicken.  Three  or  four  hours  later  the  stomach  contents 
are  aspirated,  and  tryptophan  tested  for.  If  present,  he 
considers  reaction  positive;  if  absent,  the  filtrate  is  placed 
in  a  thermostat  and  tested  for  tryptophan  twenty-four  or 
forty-eiglit  hours  later.  When  a  negative  troptophan  test 
is  obtained  in  a  case  of  pyloric  stenosis  showing  free  hydro- 
chloric acid,  lavage  may  be  instituted,  and  Ewald's  test 
breakfast  given  in  hope  that  contents  may  be  free  of  free 
hydrochloric  acid,  and  that  the  reaction  may  be  secured. 
Acetic  acid  and  bromin  vapor  are  employed. 

In  this  test  Weinstein  claims  that  the  only  practical 
sources  of  error  are  first,  the  presence  of  free  hydrochloric 
acid  equal  to  0.36  per  cent.,  though  he  has  noted  exceptions; 
and  second,  the  regurgitation  of  duodenal  contents  so  that 
the  contained  trypsin  may  produce  tryptophan.  He  does 
not  believe  that  occult  blood  or  bacteria  interfere  with  the 
test. 

These  tests  have  been  studiously  followed  up  by  Fried- 
man and  others,  and  a  considerable  difference  of  opinion 
prevails  in  regard  to  the  factors  which  may  invalidate  them. 
At  present  this  test  is  not  as  enthusiastically  regarded  as 
formerly. 

Attempts  have  been  made  to  apply  the  principle  of 
complement  deviation,  which  has  been  of  so  much  use  in  the 
diagnosis  of  syphilis,  to  the  early  diagnosis  of  cancer. 
Laborious  efforts  have  been  entered  into  in  the  hope  of 


472  TUMORS    or    THE    STOMACH 

finding  an  antigen,  perhaps  an  extract  of  cancerous  tissue, 
which  would  combine  with  the  antibodies  supposed  to 
exist  in  the  serum  of  patients  suffering  with  cancer.  The 
results  obtained  by  them  have  not  been  uniform,  and  it 
must  be  admitted  that  so  far  the  action  of  the  antigens  have 
not  been  specific  enough  to  certainly  differentiate  cancer 
from  syphilis,  benign  new  growths,  and  other  conditions. 

The  latest  serum  test  is  Abderhalden's  test,  concerning 
the  use  of  which  in  other  conditions  much  is  now  being 
written.  This  test  is  based  on  the  consideration  that 
when  foreign  proteins  get  into  the  blood,  the  "body  reacts 
by  elaborating  a  ferment  which  causes  their  disintegration. 
The  same  reaction  is  believed  to  occur  under  the  influence  of 
certain  peculiar  protein  substances  derived  from  the 
organism  itself.  As  elements  from  the  placenta  pass  into 
the  maternal  blood,  the  serum  acquires  the  power  to  digest 
placental  tissue,  and  Abderhalden  believes  this  to  be  present 
only  in  pregnancy. 

As  his  test  for  pregnancy  is  based  on  this  principle,  so, 
asks  the- Journal  of  the  A.  M.  A.,  may  it  not  be  possible  that 
in  cancer  analogous  reactions  occur,  so  that  the  serum  of 
cancerous  patients  may  be  able  to  digest  cancerous  tissue  ? 
If  this  should  be  the  case,  the  detection  of  the  products  of 
such  digestion  would  present  a  means  of  specific  diagnosis. 
The  method  is  as  follows :  A  small  piece  of  cancerous  tissue 
is  placed  in  a  dialyzing-sack  and  covered  with  a  few  cubic 
centimeters  of  the  serum  of  the  suspected  cancer  patient; 
this  sack  is  put  in  a  2  per  cent,  solution  of  sodium  fluorid  in 
a  suitable  container,  and  the  whole  placed  at  22°  C.  for 
thirty-six  hours.  At  the  end  of  this  time  the  fluid  outside 
of  the  dialyzer  is  tested  for  the  products  of  protein  digestion. 
The  presence  of  peptones  signifies  a  positive  result — the 
patient  has  cancer.  Perfect  sterility  must  be  observed 
throughout  this  method,  as  contamination  of  any  sort  spoils 
the  result. 

Kabanow  states  that  he  has  applied  the  test  with 
preparations  made  from  various  portions  of  the  gastroin- 


X-RAY    EXAMINATION   FOR    CANCER  473 

testinal  tract,  portions  which  seem  to  be  physiologically 
and  anatomically  independent  of  each  other.  He  thus 
applied  the  test  with  preparations  made  separately  from  the 
fundus,  the  pylorus,  the  duodenum,  small  intestine,  large 
intestine  and  appendix,  and  tabulates  the  details  of  sixteen 
cases.  It  is  remarkable  to  note  the  positive  reaction  to  the 
special  organ  tissue  involved,  and  the  lack  of  reaction  in 
presumably  purely  nervous  affections.  One  table  reports 
the  findings  in  four  cases  of  pernicious  anemia ;  the  reaction 
was  positive  to  stomach  and  small  intestine  tissue  in  one 
case ;  to  the  latter  alone  in  two  others,  and  there  was  no  reac- 
tion in  the  case  of  a  patient  who  had  entirely  recovered  from 
the  anemia.  The  only  contradictory  finding  was  in  a  case 
of  acute  gastritis.  The  test  was  applied  the  third  day,  and 
there  was  no  reaction,  evidently  because  the  ferments  had 
not  yet  had  time  to  appear  in  the  blood. 

Erpicum  has  tested  the  serum  of  forty -two  patients  with 
tumors  in  various  parts,  the  exact  nature  of  which  was 
determined  after  operation.  Of  these  tumors  all  the 
cancers  (two  sarcomas)  gave  positive  results.  The  benign 
tumors  gave  negative  results.  Should,  upon  further  ex- 
perimentation along  this  line,  the  same  positive  results 
be  obtained,  the  early  diagnosis  of  cancer  by  specific  means 
will  be  practically  an  accomplished  fact. 

X-ray  Examination  for  Cancer  of  the  Stomach. — The  use 
of  this  method  in  the  early  or  late  diagnosis  of  cancer  has 
been  to  a  certain  extent  discussed  in  a  special  chapter. 
Holzknecht  firmly  believes  that  a  diagnosis  of  early 
carcinoma  is  justified,  if  in  a  patient  with  achylia,  six  hours 
after  the  meal  bismuth  residue  is  found  in  the  stomach, 
provided  that  the  head  of  the  bismuth  column  has  at  this 
time  reached  the  splenic  flexure,  and  that  the  second 
bismuth  meal  shows  a  normal  stomach  shadow.  He 
reasons  on  the  hypothesis  that  as  normally  the  head  of  the 
bismuth  column  should  in  six  hours  reach  only  the  hepatic 
flexure,  we  are  dealing  with  hypermotility,  when  the  splenic 
flexure  shows  the  bismuth,  which,  when  the  pylorus  is  free, 


474  TUMORS   OF   THE   STOMACH 

is  a  regular  accompaniment  of  achylia.  The  bismuth 
residue,  moreover,  demonstrates  an  achyHa  with  stagnation, 
but  his  stipulation  that  the  contour  of  the  stomach  after 
the  second  bismuth  meal  should  be  normal,  excludes  atony 
and  many  cases  of  ulcer. 

It  appears  to  Lockwood,  and  his  view  is  concurred  in  by 
myself  and  others,  that  the  claims  of  Holzknecht  are  too 
positive,  as  ulcers  near  the  pylorus  which  occasionally 
happen  to  be  associated  with  achylia,  may  produce  the 
same  radiographic  picture,  and  that  a  differential  diagnosis 
from  pylorospasm  due  to  gall-bladder  disease  accompanied 
by  achylia,  would  be  quite  impossible.  Morphinism,  too, 
must  be  excluded  as  a  possible  cause,  as  among  these 
habitues  pylorospasm  and  bismuth  retention  may  be  found 
in  their  stomachs,  which,  after  the  second  bismuth  meal  are 
seen  to  retain  their  normal  size  and  shape,  but  in  mor- 
phinism there  would  be  no  bismuth  at  the  splenic  flexure. 

The  following  suggestions  from  Lockwood  properly  apply 
to  conclusions  derived  from  radiographs: 

In  extensive  and  infiltrating  cancerous  growth  radio- 
graphs may  show  nodular  indentations,  ' '  similar  to  finger 
prints,"  as  expressed  by  Cole.  When  the  destructive 
process  is  extensive,  large  areas  of  the  stomach  may  be 
entirely  obliterated,  the  ragged  edge  of  the  uninvolved  area 
sharply  limiting  the  outline  of  the  bismuth  shadow. 

Should  the  pylorus  be  obstructed  by  the  tumor,  the  nar- 
row constricted  lumen  of  the  pylorus  may  give  passage  to 
an  abnormally  thin  line  of  bismuth,  sinous  and  crooked. 
Sometimes  the  bismuth  outline  narrows  down  to  the  sem- 
blance of  a  cone,  with  a  small  outlet  the  apex.  In  other 
instances  a  thread-like  shadow  may  issue  directly  from  the 
sharply  defined  edge  of  an  apparently  normal  pars  pylorica. 
In  some  instances  the  stomach  is  found  to  be  empty  in  six 
hours,  but  has  lost  its  normal  hook  shape,  and  has  assumed 
a  "horn-shape."  This  picture  is  looked  upon  with  much 
confidence  by  the  radiologists,  and  when  they  make  out 
with  distinctness  that  the  "horn-shape"  is  present,  they 


DIAGNOSIS    OF   TUMORS    OF   THE    STOMACH  475 

generally  consider  that  the  growth  has  reached  the  inoper- 
able stage.  This  has  happened  several  times  in  patients  of 
the  writer. 

In  conditions  of  inoperable  diffuse  cancer  in  which  the 
whole  organ  is  involved,  we  may  find  the  stomach  empty  in 
six  hours,  the  head  of  the  bismuth  column  at  or  beyond  the 
splenic  flexure,  and  a  bismuth  deposit  in  the  lower  esopha- 
gus after  six  hours.  The  second  bimuth  meal  may  show  a 
greatly  distorted  stomach  lying  obliquely  in  the  abdomen, 
and  the  bismuth  immediately  after  ingestion  beginning  to 
flow  freely  out  of  the  stomach,  indicating  insufficiency  of 
the  pylorus. 

The  X-ray  is  a  most  valuable  adjunct  in  the  early  diagno- 
sis of  malignant  growths  of  the  stomach,  but,  like  other 
methods,  cannot  be  depended  on  to  the  exclusion  of  other 
well-known  and  well-tried  clinical  investigations. 

Differential  Diagnosis. — There  are  several  conditions 
which  may  in  certain  particulars  simulate  carcinoma  ven- 
triculi,  and  will  be  briefly  considered. 

Apparent  Tumors  of  the  Stomach. — Prolapse  of  the  left 
lobe  of  the  liver,  a  pulsating  aorta,  or  a  thickened  portion  of 
the  abdominal  recti  muscles  have  been  mentioned  by 
Einhorn  as  being  mistaken  for  a  tumor  of  the  stomach. 
The  history,  general  appearance  of  the  patient,  and  careful 
examination  will  suffice  to  eliminate  cancer. 

Grave  Anemia  in  Cancer  without  Palpable  Ttunor. — • 
These  cases  show  dyspeptic  symptoms,  and  must  be  differ- 
entiated from  pernicious  anemia.  The  blood  findings,  as 
previously  stated,  will  mark  the  difference.  It  might  be 
said  in  addition  that  the  gastric  acidity  of  the  stomach 
contents  is  higher  in  cancer  than  with  the  achylia  of 
pernicious  anemia,  and  lactic  acid  may  be  present  in  can- 
cerous anemia.  With  secondary  anemia  or  chlorosis, 
hyperchlorhydria  is  generally  associated. 

Syphilis. — This  sometimes  presents  a  syndrome  of  symp- 
toms, plus  gummatous  masses  in  or  around  the  stomach, 
that   will   deceive   the   most   experienced   observer.     The 


476  TUMORS    OF    THE    STOMACH 

history  will  have  to  be  carefully  noted  and  a  Wassermann 
test  made.  While  the  writer  does  not  subscribe  with 
great  confidence  to  the  Wassermann  test,  it  may  be 
accorded  a  modicum  of  weight  when  corroborated  by  other 
evidence.  As  an  antiulcer  treatment  is  helpful  in  clearing 
up  a  diagnosis,  so  an  antisyphilitic  treatment  may  be  util- 
ized, and  the  results  noted. 

Sclerosis  of  the  Stomach. — ^This  is  usually  found  in 
persons  past  middle  life,  who  complain  of  pain  in  the 
stomach,  distention  after  eating  if  they  attempt  any 
physical  exertion,  and  dyspnea,  relieved  by  the  eructation 
of  gas.  They  also  complain  of  nocturnal  seizures,  ac- 
companied by  distention,  heart  disturbances,  dyspnea,  and 
sense  of  impending  danger.  On  examination  there  is 
found  a  heart  somewhat  enlarged,  a  sharp  aortic  second 
sound,  a  murmur  over  the  aortic  area,  pulsation  in  the 
episternal  notch,  attacks  of  pain  over  the  precordial  region 
radiating  to  the  left  arm,  and  marked  tenderness  over  the 
abdominal  aorta  down  to  the  umbilicus.  All  these  show 
the  circulatory  system  as  the  real  origin  of  the  trouble. 

Aneurysm  of  the  Celiac  Simulating  Carcinoma  of  the 
Pylorus. — The  possibility  of  this  error  is  interesting. 
Kemp  reports  a  negro  patient,  in  whom  were  vomiting, 
gastric  pain,  anorexia,  etc.,  and  a  loss  of  40  pounds  in  three 
months.  A  palpable  tumor,  the  size  of  a  small  egg,  was 
present  in  the  epigastrium,  in  which  there  was  a  slight 
pulsation,  but  no  bruit  or  thrill.  Exploration  showed  an 
aneurysm  of  the  celiac  axis  pressing  on  the  pylorus  pos- 
teriorly, causing  occlusion  of  the  pylorus  and  other  diges- 
tive disturbances. 

Prognosis. — If  diagnosed  very  early,  surgical  treatment 
offers  a  moderate  amount  of  hope,  and  some  cases  are  on 
record,  where,  after  resection  of  the  pylorus,  or  even  the 
major  part  of  the  stomach,  the  patients  have  lived  several 
years.  Kocher  has  reported  an  instance  in  which  the 
patient  was  in  good  health  five  and  a  half  years  after  re- 
section  of  the  pylorus  for   carcinoma;   and   Wolfler  one 


MEDICAL    TREATMENT    OF    CANCER  477 

where  the  patient  remained  well  for  five  years,  dying  of  a 
metastasis.  Criete,  of  Gottingen,  mentions  a  case,  in  which 
the  patient  was  still  in  seeming  perfect  health  fourteen  years 
after  resection  of  the  pylorus  for  cancer.  These  cases, 
however,  are  infrequent.  Deaver  shows  that  about  lo 
per  cent,  may  be  cured  by  early  and  radical  operation,  and 
perhaps  that  is  about  the  best  we  can  expect. 

Medical  aid  can  alleviate  the  suffering  and  prolong  life; 
it  can  do  no  more. 

MEDICAL  TREATMENT  OF  GASTRIC  CANCER 

Medical  treatment,  while  not  curative,  has  an  important 
place  in  the  amelioration  of  the  symptoms,  relieving  the 
pain,  nourishing  the  patient,  and  smoothing  in  many 
ways  the  downward  path  which  leads  to  the  inevitable 
termination. 

The  treatment  naturally  divides  itself  into  the  dietetic, 
mechanic,  and  medicinal,  and  should  be  directed  entirely 
according  to  the  location  of  the  lesion. 

Dietetic. — In  carcinoma  of  the  pylorus,  if  the  stenosis  is 
not  already  of  sufficient  gravity  to  produce  marked  stagna- 
tion of  the  stomach  contents,  the  diet  must  consist  of  liquid 
and  semi-solids,  rich  in  liquid  fats,  as  butter,  cream,  or  olive 
oil.  In  carcinoma  not  involving  the  pyloric  region,  the  diet 
suited  to  atrophic  gastritis  is  fairly  appropriate,  including 
milk,  farinaceous  foods,  soup  with  finely  divided  vegetables, 
as  peas,  beans,  or  potatoes;  broths,  gruels,  raw  or  soft-boiled 
eggs,  butter  and  cream  in  plenty,  weak  tea  or  coffee,  and 
milk  toast.  In  some  cases  there  may  be  given  with 
satisfaction  chicken,  squab,  scraped  meat,  stale  bread, 
oysters,  fish,  etc.  A  valuable  addition  to  nearly  any 
cancer  dietary  consists  of  raw  eggs  beaten  up  in  milk,  and 
the  more  of  these,  up  to  eight  or  ten  a  day,  the  better. 
Food  should  be  administered  in  small  meals,  four  to  eight 
a  day.  The  caloric  value  of  the  food  ingested  is  not  as  fit 
a  criterion  as  the  patient's  weight,  and  the  scales  should  be 
used  frequently. 


47^  TUMORS    OF   THE    STOMACH 

Mechanic  Treatment. — When  there  is  marked  downward 
displacement  of  the  stomach  or  other  abdominal  viscera,  a 
Rose  belt,  not  too  firmly  applied,  will  in  many  instances 
afford  marked  comfort. 

Local  applications  in  the  form  of  hot  stupes,  moist  hot 
trunk  packs,  and  dry  heat,  to  lessen  the  pain  and  relax 
muscular  spasm  are  indicated.  The  use  of  electricity  or 
massage  is  not  to  be  recommended. 

Lavage  possesses  a  most  useful  place  in  the  treatment, 
especially  when  the  motor  function  of  the  stomach  is  dis- 
turbed. In  motor  insufficiency  of  the  first  degree  it  is  not 
necessary  to  wash  the  stomach  every  day — probably  two 
or  three  times  a  week;  but  in  motor  insufficiency  of  the 
second  degree,  or  where  the  pylorus  is  markedly  con- 
stricted, the  lavage  should  be  performed  every  day,  prefer- 
ably at  night  before  supper.  This  seems  to  exert  a  pleasing 
influence,  relieving  many  distressing  symptoms,  decreasing 
the  pains,  and  permitting  an  improvement  in  nutrition. 
Lavage  cannot  arrest  the  advancing  cachexia  resulting  from 
cancer,  but  in  spite  of  the  gradually  progressive  weakness, 
it  enables  patients  to  remain  free  from  many  subjective 
symptoms  which  would  otherwise  render  their  existence  a 
greater  burden.  The  lavage  should  be  followed  by  an  anti- 
fermentative  solution,  as  liquor  alkaline  antiseptic,  ichthyol, 
or  potassium  permanganante,  and  the  operation  should  be 
performed  as  expeditiously  as  possible,  for  each  lavage 
requires  a  certain  amount  of  effort  on  the  part  of  the 
weakened  sufferer. 

Medical  Treatment.^ — -The  object  of  this  is  the  increasing 
of  appetitie,  the  improvement  of  digestion,  and  the  relief  of 
pain. 

Condurango  has  been  employed  most  frequently  as  a 
medicinal  agent  for  the  stimulation  of  appetite,  and  was  at 
one  time  given  empirically  as  possessing  certain  curative 
virtues.  While  this  view  is  no  longer  accepted,  condurango 
certainly  aids  the  appetite.  It  can  be  given  in  the  form  of  a 
decoction  or,  that  not  being  easily  prepared,  the  tincture 


MEDICAL   TREATMENT   OF    CANCER  479 

may  be  employed,  fifteen  drops  in  water  three  or  four  times 
daily.  This  may  with  benefit  be  combined  with  mix 
vomica,  cinchona,  gentian,  or  the  other  bitter  stomachics. 
When  there  is  no  free  hydrochloric  acid,  orexin,  in  3 -grain 
doses,  given  two  hours  before  meals,  sometimes  yield  happy 
results. 

For  the  gaseous  eructations,  there  may  be  given  resorcin, 
combined  with  milk  of  magnesia  or  bismuth,  and  aided  in 
its  carminative  action  by  spirits  of  anise  or  compound 
tincture  of  cardamom,  as  laid  down  in  the  chapter  on  drug 
therapy. 

Methylene  blue  has  been  advocated  by  some  for  long- 
continued  use  in  inoperable  cases.  This  drug,  adminis- 
tered in  3 -grain  doses,  will  do  no  harm,  and  may  be  tried  as 
a  last  resort. 

The  "trypsin  treatment,"  so  confidently  vaunted  a  few 
years  ago,  is  without  value,  and  has  fallen  into  disrepute. 

The  pain  will  demand  anodynes,  and  either  tincture  of 
opium  or  morphin  may  be  allowed,  or  the  latter  given  hypo- 
dermically.  It  is  well  to  remember,  however,  that  when 
once  started  these  anodynes  will  need  to  be  given  till  the 
end,  and  generally  in  rapidly  increasing  doses. 

The  X-rays  have  been,  and  are  still  used  in  inoperable 
cancerous  growths;  and  radium,  deposited  in  radium  re- 
ceptacles, which  consist  of  hard-rubber  capsules  attached 
to  a  silk  thread,  has  been  introduced  into  the  stomach  like 
the  stomach  bucket.  This  is  retained  in  the  stomach  one 
hour.  The  X-rays  and  the  radium  may  be  used,  if  desired, 
and  may  exericse  some  beneficial  effect.  They  are  at  least 
worth  the  trial. 

Adamkiewicz  has  employed  a  serum  called  "cancorin," 
and  Doyen  has  advanced  a  "cancer  cure  serum,"  both  of 
which  seem  to  have  failed  to  afford  any  tangible  effects. 
Good  results  in  the  way  of  producing  a  shrinkage  and  soften- 
ing of  the  cancerous  masses  have  been  reported  from  the 
use  of  "cancrodin,"  made  by  Schmidt,  of  Cologne. 

Coley's  fluid  (toxins  of  the  streptococcus  of  erysipelas  and 


480  TUMORS    OF    THE    STOMACH 

of  bacillus  prodigiosus)  has  been  tried,  and  in  some  cases  of 
inoperable  sarcoma  has  appeared  to  afford  at  least  some 
temporary  relief.  Coley  recommends  its  use  also  after 
operation  for  carcinoma  to  lessen  the  chances  of  recurrence. 
The  injection  of  this  fluid  should  be  begun  with  1/4 
minim  diluted  with  sterile  water  to  ensure  accuracy  of 
dosage.  Daily  injections  should  be  given,  increasing  by 
1/4  minim,  until  the  desired  reaction  and  a  temperature  of 
102°  to  104°  P.  has  been  obtained.  The  dose  should  then 
remain  stationary  until  it  fails  to  give  a  reaction,  when  it 
can  be  again  increased  by  1/4  minim  again  until  a  reaction 
is  obtained;  and  so  on.  The  largest  dose  has  been  7  or 
8  minims.  The  duration  of  the  treatment  may  be  from  six 
weeks  to  four  months,  and  in  some  cases  of  inoperable 
sarcoma  from  thirty  to  eighty  injections  have  been  given. 
This  method  is  certainly  worth  trying,  and  may  accomplish 
some  good,  when  nothing  else  seems  available. 

The  systematic  use  of  aromatic  liquid  albolene  in  dram 
doses,  four  to  six  times  daily,  or  olive  oil  in  1/2 -ounce  doses 
three  or  four  times  daily,  is  soothing  to  the  bowels  and 
helpful  to  the  orderly  and  unirritating  progress  of  the  fecal 
current.  As  a  general  rule  cathartics  should  be  avoided, 
and  simple  enemas,  or  those  to  which  a  little  milk  of 
asafetida  or  turpentine  has  been  added  should  be  depended 
upon  to  keep  the  bowels  empty.  Should  there  be  very 
much  apparent  intestinal  toxemia,  the  following  prescrip- 
tion will  generally  answer,  and  it  will  probably  cause  neither 
nausea  nor  griping: 

I^.     Hydrarg.  chlor.  mitis, 

Phenolphthalein aa  gr.  ss. 

Sacch.  lactis gi".  v. 

Ft.  chartute  No.  5. 
SiG. — One  powder  dry  on  tongue  every  half  hour  till  taken. 

Should  diarrhea  complicate  the  situation,  the  bismuth 
preparations,  especially  the  subgallate,  are  of  service.  I 
often  use  the  milk  of  bismuth  as  a  vehicle,  and  add  to  it,  as 
indicated,   tincture  of  opium,    catechu  or  kino,   or  other 


FOREIGN  BODIES   IN   THE    STOMACH  48 1 

astringents.  I  have  also  found  the  lo-grain  doses  of  tanni- 
gen,  one  given  after  each  loose  bowel  movement,  satis- 
factory. 

Finally,  the  cheering  and  sustaining  influence  of  optimis- 
tic psychotherapy  should  never  be  denied  these  unfortunate 
sufferers,  for,  while  little  may  be  done  for  the  disease, 
much  may  be  done  for  the  patient,  and  the  encouraging 
word  or  hand  grasp,  the  sympathetic  interest,  and  the  evi- 
dent determination  of  the  physician  to  leave  no  stone  un- 
turned— all  these  will  exert  their  favorable  influence  upon 
the  cancer  victim,  aiding  him  in  his  desperate  and  losing 
conflict  with  the  powers  of  disease. 

FOREIGN  BODIES  IN  THE  STOMACH 

Many  and  varied  are  the  foreign  bodies  that  are  swal- 
lowed, either  accidentally  or  purposely.  Insane  patients 
sometimes  swallow  any  article  that  can  be  gotten  down 
the  esophagus,  and  some  intelligent  individuals  seem  to  fall 
into  the  habit  of  unconsciously  swallowing  such  articles  as 
bits  of  wood,  pieces  of  finger  nails,  balls  or  bits  of  hair,  or 
other  small  substances  that  find  their  way  into  the  mouth. 

Among  the  many  articles  reported  as  finding  entrance  to 
the  stomach,  are  pins,  needles,  scarf-pins,  knives,  spoons, 
forks,  artificial  teeth,  glass,  hooks,  pens,  buttons,  balls  of 
hair,  bits  of  iron,  nails,  lead,  wood,  and  even  the  stomach- 
tube.  Long-continued  swallowing  of  hair  has  resulted  in 
hair-balls  of  surprising  size,  and  in  dealing  with  the  men- 
tally irresponsible  the  physician  need  not  be  surprised  at 
finding  in  the  cavity  of  that  long-suffering  organ,  the 
stomach,  the  most  bizarre  commodities. 

Vandivert  and  Mills  report  a  case  from  the  State 
Hospital,  St.  Joseph,  Mo.,  in  which  a  patient  died  ap- 
parently from  nephritis,  and  with  no  special  suspicions  of 
gastric  trouble  until  autopsy.  This  disclosed  a  mass  of 
foreign  material  lying  on  the  sacculated  portion  of  the 
stomach,  leaving  only  a  narrow  channel  along  the  lesser 
31 


482  TUMORS    or    THE    STOMACH 

curvature  for  the  passage  of  food.  There  was  atrophy  of 
the  mucous  membrane,  much  formation  of  connective  tis- 
sue, erosions,  and  the  points  of  some  of  the  foreign  bodies 
had  penetrated  the  stomach  walls,  but  the  adherent  omen- 
tum prevented  leakage.  There  were  several  small  walled- 
in  abscesses.  The  appetite  remained  good  until  two  weeks 
before  death,  and  no  symptoms  referable  to  the  stomach 
were  complained  of.  In  all,  1446  objects  were  found  in  the 
stomach. 

Occasionally,  when  the  swallowed  body  is  rather  large,  it 
may  be  arrested  at  some  point  in  the  esophagus,  though  the 
patient  will  think  it  has  passed  into  the  stomach. 

Diagnosis. — There  may  be  local  disturbances  of  severe 
type  and  vomiting,  or  if  damage  be  done  to  the  mucous 
membrane,  there  may  be  profuse  hemorrhage.  On  the 
other  hand,  there  may  be  little  if  any  disturbance,  and  the 
foreign  body,  if  small  or  fairly  smooth  may  be  evacuated 
from  the  bowels.  Sometimes  the  foreign  substance,  as 
swallowed  hair,,  may  become  quite  large,  forming  a  large 
and  palpable  tumor.  Several  cases  of  hair-balls  have  been 
reported  in  which  the  collection  of  hair  formed  a  solid  mass 
as  large  as  the  cavity  of  the  stomach,  and  accurately  con- 
forming to  its  shape. 

The  X-rays  may  be  depended  on  to  give  the  desired  in- 
formation as  to  the  presence  of  these  foreign  bodies,  and 
together  with  the  previous  history  will  furnish  the  nec- 
essary data  as  to  their  location.  In  the  case  of  hair-balls, 
the  mass  itself  does  not  cast  a  radiographic  shadow,  and 
they  may  simulate  inoperable  growths.  The  following 
from  a  case  of  Dr.  A.  E.  Barclay,  gives  his  description  of  the 
methods  employed,  and  appearances:  "The  examination 
was  conducted  in  the  erect  posture,  and  in  all  such  cases 
bismuth  food  is  given  in  order  to  establish  the  relationship 
of  the  stomach  and  other  parts  of  the  alimentary  canal  to 
the  tumor.  In  this  case  the  bismuth  flowed  into  the  stom- 
ach, and  then  began  to  canalize  down  the  greater  curvature, 
showing  very  clearly  that  the  tumor  was  not  the  spleen, 


FOREIGN  BODIES   IN   THE    STOMACH  483 

otherwise  the  greater  curvature  would  have  been  displaced 
to  the  inner  side  of  it.  At  this  stage  the  appearances  were 
those  sometimes  seen  in  advanced  cases  of  carcinoma  in- 
volving the  whole  of  the  pyloric  end  and  lesser  curvature 
of  the  stomach.  Presently,  however,  as  more  food  was 
given,  the  shadow  extended  down  the  lesser  curvature, 
apparently  around  the  mass,  which  was  evidently  not  to 
the  inner  side  of  the  stomach,  but,  either  inside,  in  front,  or 
behind  it.  A  little  manipulation  and  rotation  of  the  patient 
quickly  demonstrated  that  the  mass  displacing  the  bismuth 
(showing  as  a  lighter  area  in  the  midst  of  the  dark  shadow  of 
the  bismuth)  was  actually  within  the  stomach." 

Treatment. — Emetics  are  inadvisable,  for  forcible  and 
convulsive  efforts  of  the  stomach  are  more  liable  to  work 
harm  to  the  organ  than  to  expel  the  foreign  body.  Mr. 
Stephen  Mayou  has  devised  a  means  of  removing  small 
bodies  of  a  metallic  nature  from  the  stomach  by  passing 
down  an  electro-magnet,  enclosed  within  a  flexible  celluloid 
tube.  By  the  aid  of  the  X-ray  the  course  taken  by  the 
magnet  and  its  relation  to  the  foreign  body  can  be  clearly 
seen.  In  the  case  of  a  boy,  aged  two,  who  had  swallowed  a 
hair-pin,  this  was  removed  by  this  method  without  the 
need  of  surgical  intervention. 

When  the  physician  is  first  consulted,  and  the  patient  or, 
family  much  alarmed,  it  is  generally  not  advisable  to  at 
once  give  a  cathartic,  unless  the  object  is  smooth  like  a 
marble  or  small  ball;  otherwise  the  hurried  passage  of  the 
body  through  the  intestinal  canal  may  inflict  great  damage, 
as  perforations  or  hemorrhage. 

The  safest  and  best  method  is  to  give  constipating  food, 
as  potatoes  or  rice,  or  the  soft  part  of  bread,  keeping  the 
bowels  quiet  for  several  days  so  that  a  protective  mass  may 
envelop  the  article.  Later  on,  castor  oil  or  liquid  paraffin 
may  be  administered,  and  the  foreign  body  will  have  a 
better  chance  to  traverse  the  intestines  safely,  and  escape 
without  causing  injury. 

Should  intestinal  obstruction  ensue,  or  with  bodies  of 


484  TUMORS    OF   THE    STOMACH 

large  size  any  serious  symptoms  become  evident,  the  loca- 
tion by  the  X-ray  should  be  sought,  and  the  object  removed 
by  the  surgeon. 

Occasionally  a  small  object  may  be  located  in  the  stomach 
by  the  gastroscope,  and  removed  by  long  forceps,  or  may 
proceed  as  far  as  the  rectum,  and  be  removed  from  that. 
These  contingencies,  however,  are  extremely  rare. 

In  some  instances  the  foreign  body  escapes  without  the 
patient's  knowledge,  but  the  symptoms  persist  through 
psychic  influence.  Some  years  ago  there  was  brought  to 
me  a  girl  of  twelve  years,  who  gave  a  history  of  having 
swallowed  an  iron  tap  two  years  before.  She  complained 
much  and  bitterly  of  pains  in  her  abdomen,  but  the  X-rays 
showed  the  presence  of  no  foreign  body.  Being  convinced 
that  the  body  had  been  expelled,  the  patient  complained  no 
more,  and  has  continued  in  perfect  health. 


CHAPTER  XX 

DUODENAL  ULCER— INTESTINAL  ULCERATION 
—PROCTITIS 

With  increasing  experience  the  conviction  is  impressed 
upon  us  that  duodenal  ulcer  is  of  much  more  frequent  oc- 
currence than  was  formerly  thought.  Within  the  medical 
recollection  of  the  writer  are  recalled  the  teaching  that  ulcer ' 
of  the  duodenum  was  a  rare  disease,  generally  due  to  ex- 
ternal burns.  Up  to  ten  years  ago  duodenal  ulcer  was  not 
compared  with  gastric  ulcer  in  frequency,  but  since  that 
time  the  belief  has  been  forced  upon  the  medical  profession 
that  duodenal  ulcer  is  fully  as  common  as  gastric,  and  is  a 
possibility  always  to  be  reckoned  with  in  disease  of  the 
upper  abdomen. 

Much  of  this  change  of  view  has  been  brought  about  by 
the  Mayos  in  America  and  Moynihan  in  England,  who  have 
definitely  and  conclusively  shown  us  by  their  operative  work 
how  frequently  this  lesion  occurs. 

Mayo  has  reported  272  operations  for  duodenal  ulcer,  and 
his  statistics  showed  ulcer  more  often  on  the  duodenal  than 
the  gastric  side  of  the  pylorus.  Moynihan  has  recently 
summarized  his  previous  papers  on  the  subject,  reporting 
186  cases,  and  he  stresses  its  frequency,  making  plain  the 
definite  clinical  picture  it  presents.  As  Mayo  says,  how- 
ever, we  should  not  assume  that  duodenal  ulcers  are  more 
frequent  than  in  the  past,  but  merely  that  they  have  hereto- 
fore been  mistaken  for  something  else. 

Diagnosis. — Clinically,  duodenal  ulcer,  which  is  twice  as 
frequent  in  males  as  in  females,  asserts  itself  in  a  variety 
of  manners.  In  some  cases  of  disease,  brought  to  autopsy 
for  other  illness,  one  or  more  ulcers  may  be  found,  healed 
or  partly   healed,  in  which  no  particular  symptoms   had 

48s 


486  DUODENAL   ULCER — INTESTINAL    ULCERATION 

been  noted  in  life  that  would  point  to  such  a  lesion.  In 
some  instance  either  perforation  or  hemorrhge  are  the  first 
warnings  given.  In  the  great  majority  of  duodenal  ulcers, 
though,  symptoms  appear  in  a  definite  and  well-ordered 
sequence,  and  with  a  remarkable  precision. 

The  following  diagnostic  data  are  abstracted  from 
Moynihan: 

A  patient,  probably  past  middle  age,  complains  of  in- 
digestion. Asked  as  to  how  long  he  has  suffered,  he  may 
say,  "All  my  life."  This  frequent  answer  shows  that  the 
ulceration  may,  with  periods  of  repose,  continue  up  to 
middle  life,  or  even  to  advanced  age.  Upon  further 
questioning,  the  patient  will  relate  how  insidiously  and 
■almost  imperceptibly  he  began  to  suffer  from  a  sense  of 
weight,  oppression,  or  distention  after  meals.  At  first  the 
discomfort  was  apparently  capricious,  but  after  a  time  he 
begins  to  notice  that  the  discomfort  comes  two  hours  or  a 
little  more  after  food  has  been  taken.  Immediately  after 
a  meal  there  is  ease;  if  pain  were  present  before,  the  meal 
relieved  it.  Again  the  pain  is  felt  two,  three,  four  or  even 
six  hours  later.  When  this  pain  comes  on  three  or  more 
hours  after  food,  it  has  been  found  that  the  ulcer  was 
"tucked  back" ;  that  is  to  say,  posteriorly  in  such  a  manner 
as  to  prevent  its  delivery  into  the  abdominal  wound. 
When  the  pain  consistently  comes  on  at  an  earlier  time 
than  two  hours  after  food,  either  an  active  ulcer  has  con- 
tracted recent  adhesions  to  the  adominal  wall  or  liver,  or 
stenosis  is  beginning  to  develop.  The  interval  between  the 
taking  of  food  and  the  onset  of  pain  is  very  remarkable,  and 
is  constant  from  day  to  day  if  the  character  and  quantity 
of  food  remain  the  same.  If  the  food  is  entirely  liquid,  the 
pain  comes  rather  earlier;  if  it  is  heavy  and  solid,  the  pain 
comes  on  later.  With  an  ordinary  meal  of  liquid  and  solid, 
the  pain  very  rarely  appears  in  less  than  two  hours.  Many 
patients  will  volunteer  the  statement  that  the  pain  begins 
to  appear  "when  they  are  beginning  to  feel  hungry,"  and 
the  term  "hunger  pain,"  has  been  suggested  as  descriptive 


DIAGNOSIS    OF   DUODENAL   ULCER  487 

of  this  particular  symptom.  At  first  the  pain  is  noticed 
only  after  the  heaviest  meal  of  the  day.  If  a  heavy  dinner 
is  eaten,  for  instance,  at  i  or  2  p.  m.,  the  pain  may  be  ex- 
pected at  or  near  4  p.  m.  This  condition  may  remain 
stationary  for  quite  a  while,  but  in  the  course  of  time  the 
patient  will  notice  that  the  pain  comes  on  at  the  char- 
acteristic period  after  each  meal,  and  that  by  every  meal 
the  pain  is  relieved,  only  to  return  as  before.  Another 
characteristic  feature  of  the  pain  is  that  it  wakes  the 
patient  at  night  about  2  o'clock.  By  this  time  he  has 
generally  discovered  that  the  ingestion  of  food  mitigates 
the  pain,  and  in  most  instances  food  is  kept  at  hand,  per- 
haps a  biscuit  or  cracker  or  glass  of  milk,  so  it  can  be 
conveniently  eaten  when  needed.  The  pain  of  duodenal 
ulcer  is  often  preceded  or  accompanied  by  a  sensation  of 
weight  or  fulness  in  the  epigastrium,  and  is  described  as 
"boring,"  "gnawing,"  "burning."  It  may  be  relieved  by 
belching,  and  for  this  reason  strenuous  efforts  are  made 
to  eructate  this  gas.  There  may  be  with  the  gas  a 
slight  regurgitation  of  food,  with  a  bitter  or  acid  taste, 
leaving  in  its  wake  a  sense  of  scalding;  followed,  perhaps, 
by  a  free  gush  of  saliva.  For  long  periods,  sometimes  all 
through  the  case,  the  pain  may  be  confined  to  the  epi- 
gastrium, but  it  may  strike  through  to  the  back  or  pass 
around  the  right  side.  Sometimes  the  pain  is  severe  but 
partly  relieved  by  pressure,  and  the  patient  may  hug  a  pil- 
low to  the  abdomen  to  obtain  comfort.  In  all  probability  a 
spasm  of  the  pylorus  is  responsible  for  these  cramping  pains. 
Vomiting  is  rare,  seldom  developing  until  stenosis  arrives. 
Another  noteworthy  feature  in  this  condition  is  found  in  the 
history  of  intervals  of  apparent  health  for  a  varying  period 
of  time,  with  relapses  brought  on  seemingly  by  exposure  to 
cold,  getting  the  feet  wet,  or  eating  an  indigestible  meal. 
The  most  common  cause,  as  related  by  the  patient,  is 
"getting  cold,"  and  many  suffer  only  during  the  winter 
months. 

Moynihan    reports    one    instance  where  a  patient  was 


488  DUODENAL   ULCER — INTESTINAL    ULCERATION 

perfectly  well  for  three  years  when  in  India.  He  returned 
to  England  in  November,  and  within  two  weeks  had 
"caught  a  chill"  with  the  consequence  that  all  his  symp- 
toms returned.  The  attacks,  which  vary  from  three  weeks 
up  to  several  months,  may  sometimes  be  cut  short  by  a  rest 
in  the  country  or  at  the  seaside,  and  occasionally  an  attack 
may  determinate  as  suddenly  as  it  came  on.  In  the  in- 
terim, so  complete  may  be  the  recovery,  so  good  is  the 
appetite,  and  so  comfortable  the  digestion,  that  the  patient 
cannot  realize  that  he  has  been  suffering  from  an  organic 
affection,  and  accepts  such  a  statement  from  the  physician 
with  a  tolerant  smile  of  disbelief. 

Many  of  these  cases  have  been  erroneously  diagnosed  as 
hyperchlorhydria,  acid  gastritis,  or  even  as  gastric  neuroses, 
and  may  not  show  any  abnormalities  of  sensation  or  re- 
sistance on  physical  examination.  For  this  reason  Moyni- 
han  advances  an  opinion,  with  which  the  writer  does  not 
agree,  that  it  is  not  necessary  to  the  attaining  of  an  accu- 
rate diagnosis  that  any  examination  of  the  patient  be  made ; 
that  the  anamnesis  is  everything,  the  physical  examina- 
tion comparatively  nothing.  On  the  contrary,  there  are 
numerous  instances  where  much  and  vital  corroborative 
evidence  is  obtained  from  a  careful  physical  examination. 

Stomach  Contents.— An  Ewald-Boas  test-meal  should  be 
given  in  all  cases,  and  practically  every  one  will  be  found 
hyperacid.  As  Boas  has  said,  many  cases  of  intractable 
cases  of  "acid  dyspepsia,"  which  have  resisted  all  treat- 
ment are  in  reality  caused  by  duodenal  ulcer.  In  a  few 
cases  of  chronic  ulcer,  the  free  hydrochloric  acid  may  be 
reduced,  but  as  a  rule  those  cases  which  have  progressed  to 
stenosis  and  dilatation  of  the  stomach  have  hyperacidity; 
and  in  these  the  chief  symptoms  may  be  referred  to  me- 
chanical obstruction.  The  test  of  treatment  possesses  diag- 
nostic value  here,  for,  while  simple  hyperchlorhydria  is 
amenable  to  treatment,  when  it  is  present  with  a  history  of 
hematemesis  or  melena,  the  hyperchlorhydria  is  not  easily 
relieved  by  either  treatment  or  diet. 


DIAGNOSIS    OF   DUODENAL   ULCER  489 

The  diagnosis  of  blood  in  the  stomach  contents,  while 
characteristic  of  gastric  ulcer,  is  not  necessarily  found  in 
duodenal  ulcer,  nor  is  hematemesis  frequent.  Blood  in  the 
feces  is,  however,  quite  frequent,  and,  if  on  examination  of 
stomach  contents  no  pus  is  found,  and  occult  blood  either 
present  or  absent,  but  occult  blood  in  the  stools,  and  the 
characteristic  history  is  obtained,  a  confident  diagnosis  of 
duodenal  ulcer  may  be  made.  One  statement,  I  would 
certainly  not  make,  is  that  "  hyperchlorhydria  is  duodenal 
ulcer." 

Hemorrhage. — Though  this  is  occasionally  early,  it  is 
generally  a  late  symptom.  Visible  hemorrhage  Moynihan 
believes  a  sign  of  neglected  opporttmity.  This  hemorrhage 
may  manifest  itself  either  a  hematemesis  or  melena,  with 
dark  tarry  stools.  Hemorrhage  from  a  duodenal  ulcer  may 
be  more  insidious  and  dangerous  than  from  a  gastric  ulcer. 
When  acute,  the  patient  may  complain  of  an  exacerbation 
of  the  indigestion  and  a  feeling  of  distention.  The  patient 
may  then  suddenly  become  faint  and  weak,  the  head  covered 
with  drops  of  cold  perspiration,  pallor  of  the  face  may  show 
itself,  and  he  asks  for  air.  These  are  the  evident  signs  of 
internal  hemorrhage,  and  the  patient  may  bleed  to  death 
without  any  visible  blood.  As  a  rule,  though,  these  symp- 
toms are  followed  by  tarry  evacuations  of  the  bowels 
twenty-four  or  more  hours  later.  When  the  hemorrhage  is 
small,  there  may  be  progressive  anemia  and  weakness, 
attributed  by  the  patient  to  other  reasons.  Though  several 
examinations  may  be  required  before  occult  blood  is  found 
in  the  feces,  it  is  believed  that  by  persevering,  this  symptom 
will  be  manifested  in  every  case  of  duodenal  ulcer  at  some 
period  of  its  progress. 

Dilatation  of  the  Stomach. — In  some  cases  there  are  evi- 
dences of  dilated  stomach,  as  copious  and  repeated  vomit- 
ing, while  the  symptoms  of  active  ulceration  are  latent  or 
absent.  In  this  type,  which  can  only  be  accurately 
diagnosed    by    operation,    the    ulcer    is    generally    found 


49°  DUODENAL   ULCER — INTESTINAL  ULCERATION 

nearly  healed,  the  cicatricial  contraction  being  responsible 
for  the  stenosis  and  dilatation. 

Perforation. — This  is  the  most  serious  complication  that 
can  occur  in  the  course  of  a  duodenal  ulcer.  Finney  re- 
ports this  in  an  infant  of  two  months,  while  Moynihan  has 
encountered  it  in  a  woman  of  twenty-seven  years. 

Perforation  may  happen  suddenly  with  acute  duodenal 
ulcer  due  to  burns  or  septicemia,  or  it  may  occur  during  the 
course  of  a  chronic  ulcer,  that  has  taken  on  for  some  reason, 
active  pathologic  changes. 

Diagnosis  of  Acute  Perforation. — There  suddenly  seizes 
the  patient  an  excruciating  pain,  occasionally  so  fulminant 
that  death  quickly  follows.  He  is  prostrated,  pale  and 
faint,  with  livid  anxious  features  and  clammy  brow. 
Respirations  are  short  and  labored,  for  deep  inspirations 
increase  the  agony.  The  pulse  is  generally  rapid  and 
thready,  and  muscular  rigidity  is  followed  in  a  few  hours 
by  abdominal  distention.  Extreme  tenderness  of  the 
whole  abdominal  surface  is  usually  in  evidence.  Neither 
palpation  nor  percussion  are  willing  born  by  the  patient. 
As  the  symptoms  progress,  the  pulse-rate  rises  while  the 
pulse-character  becomes  poorer,  the  abdomen,  still  rigid, 
becomes  generally  distended,  the  temperature  may  quickly 
rise  to  102°  F.,  or  more,  intestinal  stasis  is  absolute,  though 
gas  or  small  amounts  of  feces  may  be  expelled  by  enemas, 
general  cyanosis  develops,  and  death  may  occur  in  from  a 
few  hours  to  four  or  five  days,  should  relief  not  be  afforded. 

Diagnosis  of  Subacute  Perforation  of  Duodenal  Ulcer. — 
In  this  condition,  though  the  perforation  may  be  sudden, 
there  is  a  definite  localization  of  the  fiuid,  that  escapes 
through  the  opening,  and  the  general  symptoms,  while 
similar  to  those  in  acute  perforation,  are  less  fulminant  in 
character.  Vomiting  and  prostration  may  be  present  in 
considerable  degree,  but  in  this  a  tag  of  omentum  may  plug 
the  opening,  or  peritoneal  irritation  may  cause  plastic 
lymph  deposits  on  the  base  of  the  ulcer,  so  that  a  protective 
barrier  is  formed.     There  may  result  from  this  effort  of 


TREATMENT    OF    DUODENAL    ULCER  49 1 

nature  a  later  periduodenal  abscess,  a  secondary  rupture 
into  the  general  peritoneum,  an  adhesion  of  the  ulcer  area 
to  the  abdominal  wall,  liver  or  pancreas,  the  inflammation 
may  subside,  and  the  patient  may  live  for  years  in  com- 
parative comfort  and  safety. 

Diagnosis  of  Chronic  Perforation. — In  this  complication, 
the  walls  of  the  intestine  are  slowly  eroded  by  the  ulcer, 
and  by  the  time  the  serous  coat  is  reached  a  protective 
barrier  is  thrown  out,  and  protective  adhesions  are 
formed,  so  that  process  is  circumscribed,  and  instead  of 
perforation  into  the  peritoneal  cavity,  there  is  instead,  a 
local  peritonitis.  This  may  be  followed  by  a  periduodenal 
abscess,  burrowing  in  different  directions,  or  fistulae  may  re- 
sult between  the  duodenum  and  gall-bladder,  or  pancreas; 
even  between  the  colon,  or  a  hepatic  abscess  may  form. 

One  more  diagnostic  test  proposed  by  Einhorn  is  the 
thread-test  previously  mentioned,  only  with  a  longer 
thread.  Should  the  dark  spot  appear  at  a  distance  of 
58  to  66  cm.  from  the  teeth,  in  connection  with  other 
symptoms,  the  diagnosis  of  duodenal  ulcer  is  greatly 
strengthend. 

TREATMENT  OF  DUODENAL  ULCER 

This,  except  in  acute  conditions,  should  first  be  medical. 
In  the  mild  cases  regulation  of  the  diet,  as  would  be  recom- 
mended for  marked  hyperacid  conditions,  improving  the 
general  health  by  suitable  tonics  and  other  hygienic 
measures,  may  bring  about  a  considerable  amelioration 
of  the  symptoms,  with  perhaps  a  cure.  Olive  oil 
in  tablespoonful  doses  before  meals,  or  the  liquid  albolene 
in  teaspoonful  doses  in  a  like  manner,  may  be  of  marked 
service. 

In  more  pronounced  cases  of  duodenal  ulcer,  with  hemor- 
rhages, severe  pain,  etc.,  a  strict  ulcer  cure  with  rest  in 
bed,  rectal  alimentation,  and  afterward  fluid  diet,  must  be 
-put  in  force.  In  such  cases  large  doses  of  calcined  magnesia 
or  bismuth  may  be  given  before  meals,  depending  on  the 


492  DUODENAL   ULCER — INTESTINAL  ULCERS 

state  of  the  bowels.  All  details  as  in  the  cure  for  gastric 
ulcer  must  be  carried  out,  but  if,  in  response  to  these  efforts 
conditions  do  not  improve;  if  there  come  severe  hemor- 
rhages, obstinate  spasm  of  the  pylorus,  associated  with 
cramping  pains  and  peristaltic  restlessness,  an  operation 
(usually  gastroenterostomy)  is  indicated. 

In  duodenal  ulcer  the  physician  should  generally  advise 
an  operation  sooner  than  in  gastric  ulcer,  as  the  former  is 
liable  to  more  frequent,  and  graver  complications,  as  hem- 
orrhages, perforations,  or  stenosis  of  the  pylorus,  which 
place  the  patient  in  decided  danger.  Gastroenterostomy 
in  these  cases  is  usually  attended  with  satisfactory  results, 
for  as  the  gastric  juice  is  diverted  from  the  ulcer  area,  the 
lesion  soon  heals,  and  the  previous  dangers  are  averted. 

The  complications  described  are  generally  successfully 
managed  only  by  surgery,  and  the  time  of  operation  depends 
on  the  emergent  nature  of  the  case.  Medical  treatment  in 
the  face  of  such  accidents  is  useless,  and  only  serves  to 
alleviate  pain  or  sustain  the  flagging  strength  until  surgical 
aid  may  be  obtained. 

INTESTINAL  ULCERS 

The  mucous  membrane  of  the  intestine  may  be  ulcerated 
in  every  form  and  extent,  from  erosions  no  larger  than  a 
pin-head  to  deep  ulcers  the  size  of  a  silver  dollar,  or  even 
larger;  and  these  ulcerations  may  occur  anywhere  in  the 
intestinal  tract  from  the  duodenum  to  the  anus.  These 
ulcers  may  be  classed  as  catarrhal,  decubital,  toxic,  uremic, 
embolic,  tubercular,  syphilitic,  typhoid,  dysenteric,  and 
malignant.  Catarrhal  ulceration  may  arise  from  an  espec- 
ially severe  grade  of  inflammation  of  the  mucosa.  Decu- 
bital ulcers  may  be  produced  by  pressure  of  hard  scybalse, 
especially  in  the  cecum  or  the  hepatic  or  sigmoid  flexures  of 
the  colon.  This  is  more  liable  to  occur  when  there  are  kinks 
or  angulations  along  the  course  of  the  intestine.  Decubital 
ulcers  may  also  arise  from  the  pressure  of  neighboring 
organs,   such   as   the  uterus   or  gall-bladder.     The    other 


DIAGNOSIS   OF   INTESTINAL   ULCERS  493 

intestinal  ulcers  mentioned  originate  as  their  names 
indicate. 

Tubercular  ulcers  are  rare  in  the  stomach,  but  somewhat 
frequent  in  the  intestines.  E.  C.  Thrash,  an  authority  on 
tuberculosis,  contends  that  tuberculosis  of  the  stomach, 
especially  if  any  free  acid  is  present,  is  practically  unknown. 
When  this  form  of  ulceration  invades  the  intestines,  how- 
ever, the  lesions  may  be  most  extensive,  and  they  may 
invade  the  ileum  and  colon,  seeming  to  select  by  preference 
the  cecal  region,  where  irregular  tumors  resembUng  neo- 
plasms may  be  found. 

Diagnosis. — This  condition  may  begin  with  irregular 
diarrhea,  slight  fever,  and  colicky  pains.  Hemorrhage  is 
seldom  an  early  symptom.  At  first  the  case  simulates  a 
chronic  intestinal  catarrh,  but  emaciation  and  involvement 
of  the  lungs  should  point  the  diagnostic  finger  very  soon. 
The  stools  should  be  examined  time  and  again  for  the  tuber- 
cle bacillus,  which,  if  found,  is  diagnostic.  Other  approved 
tests  for  tuberculosis  should  also  be  made.  Osier  reports 
in  some  primary  cases  of  intestinal  tuberculosis,  occasional 
fatal  hemorrhage  or  perforation,  with  the  formation  of 
pericecal  abscess  or  perforative  peritonitis,  or,  rarely, 
partial  healing,  with  great  thickening  of  the  intestinal 
walls  and  narrowing  of  the  canal. 

The  following  diagnostic  suggestions  are  quoted  from 
Nothnagel : 

' '  Ulceration  of  the  intestine  often  runs  its  course  without 
symptoms.  Even  when  a  number  are  present,  or  when  the 
ulcer  is  very  large,  the  clinical  symptoms  are  frequently 
not  at  all  proportionate  to  the  intensity  of  the  anatomic 
changes.  Significant  signs  only  are  pus  and  fibrous  tissue 
in  the  stools.  A  very  important  objective  sign,  also,  is  the 
presence  of  blood  in  the  stool,  though  this  must  be  inter- 
preted with  great  caution.  On  the  other  hand,  the  number 
of  stools  passed,  or  the  fact  that  they  are  of  liquid  consis- 
tency, will  not  aid  in  forming  any  direct  conclusions  as  to 
the  condition  present." 


494  DUODENAL   ULCER — INTESTINAL  ULCERS 

Many  and  extensive  ulcerations  may  be  suspected  when 
amebic  dysentery  is  proved  by  the  ameba  in  the  stools, 
though  in  this  condition,  too,  the  amount  of  ulceration 
cannot  be  correctly  judged  by  the  cHnical  symptoms. 

Exceptions  in  the  general  history  are  to  be  made  in  the 
case  of  duodenal  ulcer,  which  has  been  considered,  and  gall- 
bladder disease  must  be  excluded. 

The  most  important  diagnostic  fact  in  the  decision  is  the 
presence  of  pus  in  the  stools.  This  may  be  hard  to  discover 
when  the  ulcer  is  high  up  in  the  intestine,  but  if  small  gray- 
ish-white specks  are  observed  in  the  stool,  or  pus  is  seen 
under  the  microscope,  the  diagnosis  of  intestinal  ulcer  may 
be  made  with  confidence.  Mucus  alone  is  not  diagnostic 
of  ulcer. 

Ulcers  of  the  rectum  will  be  discussed  later. 

Treatment. — Hemorrhage  would  be  treated  as  that  from 
duodenal  ulcer,  when  it  is  above  the  rectum.  The  primary 
cause  should  be  appropriately  treated,  and  every  effort 
should  be  put  forth  to  build  up  the  patient's  general  health. 
Tuberculous  ulcers  or  syphilitic  ulcers  indicate  the  line  of 
treatment  to  be  employed,  and  under  this  much  improve- 
ment may  be  made. 

The  diet  should  be  unirritating,  should  contain  a  mini- 
mum of  cellulose,  and  as  a  rule  the  flesh  proteins  are  well 
borne.  Many  cases  of  ulcerated  intestinal  tract  never  heal 
because  the  patient  is  never  nourished  enough  to  furnish 
the  parts  sufficient  strength  to  institute  a  healing  process. 

Medicinally,  bismuth,  tannigen,  small  doses  of  silver 
nitrate,  or  other  of  the  vegetable  astringents  are  indicated. 
Opium  and  its  derivatives  should  be  avoided,  if  possible. 
High  injections  are  not  of  service  except  in  rectal  or  low 
colonic  ulcers. 

PROCTITIS 

Proctitis  deserves  the  first  place  among  diseases  of  the 
rectum,  not  only  on  account  of  the  frequency  of  its  occur- 
rence, but  because  it  is  responsible  for  many  abnormal 


PROCTITIS  495 

conditions  high  up  in  the  abdomen,  that  are  looked  upon  as 
distinct  disease  entities.  I  am  more  convinced,  as  my  experi- 
ence broadens,  that  acute  irritation  and  inflammation  of  the 
rectum  may  reflexly  set  up  a  disturbance  at  practically 
any  point  in  the  digestive  canal.  This  has  been  specially 
impressed  upon  me  on  witnessing  sundry  digestive  disorders 
markedly  abate  when  acute  rectal  irritation  is  cared  for. 

Proctitis  may  be  produced  by  a  variety  of  causes,  and 
may  be  acute,  subacute,  or  chronic,  the  last  two  being  gen- 
erally designated  rectal  catarrh. 

The  acute  form  is  often  encountered  in  general  practice 
among  persons  of  all  ages,  and  at  times  the  true  condition 
may  be  masked  by  symptoms  that  direct  attention  higher 
up  in  the  abdomen.  The  acute  condition  will  generally 
soon  disappear  upon  removal  of  the  exciting  cause,  but  when 
it  merges  into  the  chronic  state,  it  tends  to  remain  indefi- 
nitely, with  the  formation  of  mucous  channels  in  the  rec- 
tal walls  and  perirectal  spaces. 

Diagnosis  of  Acute  Proctitis. — Pain,  heat,  burning,  ful- 
ness, tenesmus,  hypersecretion  of  mucus,  and  a  constant 
desire  to  evacuate  the  bowels,  the  last-named  being  caused 
by  the  tumefied  mucous  membrane  giving  the  sensation  of 
a  foreign  body  in  the  rectum.  Sometimes  the  pain  is 
agonizing,  and  the  continual  straining  may  bring  about 
prolapse  of  the  mucous  membrane,  and  from  this  mem- 
brane, engorged  by  sphincteric  contraction,  a  hemorrhage 
may  arise.  There  may  also  come  an  involvement  of  the 
bladder  on  account  of  its  close  proximity  and  nerve  connec- 
tion, with  an  almost  constant  desire  to  urinate. 

Mild  attacks  give  the  patient  little  more  than  a  sense  of 
discomfort,  but  whenever  these  symptoms  exist  in  a  milder 
form  with  persistence,  a  chronic  form  may  be  suspected. 
Some  of  these  patients  will  give  a  recital  of  repeated  attacks 
of  rectal  discomfort  during  ten  or  twenty  years,  with  a 
history  of  no  careful  examination,  and  only  paUiative 
treatment. 

Examination  with  the  Brinkerhoff  speculum  will  show 


496  DUODENAL   ULCER — INTESTINAL   ULCERS 

the  rectal  mucous  membrane  a  fiery  red,  with  numerous 
deeply  engorged  spots  and  perhaps  eroded  areas,  produced 
by  the  rubbing  of  the  walls  of  the  rectum  during  the 
intense  straining. 

Treatment. — This  is  largely  symptomatic.  When  the 
acute  condition  is  caused  by  irritation  or  infection,  the 
alleviation  of  the  more  pronounced  symptoms  is  first 
demanded.  The  patient  finds  that  the  reclining  position  is 
most  comfortable,  as  it  facilitates  the  emptying  of  the  con- 
gested parts.  The  first  indication  is  irrigation  of  the  rec- 
tum, so  as  to  remove  all  particles  of  feces  and  mucus,  which 
act  as  irritants.  Hot  water  is  generally  more  comfortable 
to  the  patient  than  cold,  though  some  fear  the  hot  water  on 
account  of  the  already  present  heat  and  burning.  This 
burning  sensation  is  generally  soothed  by  the  hot  water,  but 
if  the  patient  really  finds  the  hot  water  uncomfortable,  cool 
or  cold  water  may  be  substituted.  Albright  recommends  a 
beginning  of  water  at  100°  with  gradual  raising  to  120°. 
The  last  is  rather  hot,  and  it  might  be  well  to  stop  somewhat 
short  of  that  temperature.  Common  salt  (one  teaspoonfiil 
to  half-gallon  of  water)  is  a  good  solution,  or  boric  acid  in 
the  same  proportion. 

As  soon  as  a  moderate  degree  of  comfort  is  brought  on, 
the  origin  of  the  trouble  should  be  sought,  and  if  there  seems 
to  be  fecal  irritation  higher  up,  a  thorough  evacuation  of 
the  whole  intestinal  canal  should  be  obtained,  preferably 
by  an  efficient  hydragogue  cathartic.  After  the  bowels 
are  well  emptied,  irrigations  may  again  be  practised,  con- 
tinuing them  for  fifteen  to  thirty  minutes,  and  repeating 
them  every  two  or  three  hours,  except  at  night  when  the 
patient  is  asleep.  The  method  of  irrigation  has  been  pre- 
viously described.  Among  the  solutions  now  indicated  are 
boric  acid,  ichthyol,  non-alcoholic  hydrastis,  and  an  occa- 
sional use  of  silver  nitrate  solution,  4  grains  to  the  pint. 
After  each  irrigation  a  small  quantity  of  soothing  ointment 
may  be  introduced  into  the  rectum,  or  an  occasional  opium 
and  belladonna  suppository. 


PROCTITIS   AND   PERIPROCTITIS  497 

The  patient  should  be  kept  on  a  Hquid  diet  for  several 
days,  and  the  return  to  regular  diet  should  be  gradual,  care 
being  observed  that  no  food  is  taken  that  would  leave  an 
irritating  residue.  The  internal  antiseptics  are  of  but  lit- 
tle value  in  this  condition. 

Proctitis  and  Periproctitis. — This  may  involve  the  rectum 
and  part  of  the  sigmoid  flexure,  the  latter  being  termed 
sigmoiditis,  though  the  distinction  is  one  of  name  only. 
When  inflammation  once  invades  the  lower  end  of  the  intes- 
tinal tract,  through  the  medium  of  infection  or  traumatism, 
there  are  so  many  and  varied  causes  of  irritation  that  it 
extends  to  other  portions  of  the  bowel  and  may  extend 
through  its  several  coats  into  the  surrounding  tissues, 
producing  periproctitis.  Jamison  believes  that  some  of 
the  chronic  proctitis  may  be  traced  back  to  an  infection 
from  the  diaper  saturated  with  urine,  worn  during  the  first 
year  of  the  patient's  life.  Other  causes  may  be  traced  to 
improper  food,  digestive  disorders,  and  especially  to  the 
unwise  use  of  purgatives. 

Proctitis,  in  the  gradually  developing  stage,  gives  rise  to 
no  marked  discomfort,  and  may  be  present  for  years  before 
its  presence  is  discovered,  the  occasional  exacerbations 
being  ascribed  to  some  indiscretion  of  diet,  or  "catching 
cold."  As  repeated  attacks  occur  there  is  a  constant 
increase  of  tissue  formation,  with  a  consequent  lessening 
of  the  caliber  of  the  bowel,  accompanied  by  impairment  of 
function  and  muscular  contraction  and  constriction.  With 
this  progressive  inflammation  comes  the  exudation  of 
mucus,  so  often  found  in  rectal  diseases,  and  which  so  annoys 
and  distresses  the  patient.  Were  the  inflammation  con- 
fined to  the  mucous  coat  of  the  rectum  there  wotild  be 
comparatively  little  trouble  in  applying  the  proper  remedy, 
but  in  its  progress  it  may  involve  not  only  the  muscular 
coat,  but  passes  through  this  coat  into  the  perirectal  tissues, 
and  from  them,  as  well  as  the  mucous  membrane,  the  exu- 
date continues. 

The  product  of  infiammation  arising  from  the  mucous 
32 


498  DUODENAL   ULCER — INTESTINAL   ULCERS 

surface  accumulates  in  the  rectum  until  carried  out  by 
defecation ;  but  that  which  arises  from  the  deeper  structures 
accumulates  and  travels  in  the  course  of  least  resistance, 
forming  in  some  instances  sacs  or  pouches,  and  in  others  it 
burrows  in  one  or  more  directions  thus  bringing  about  the 
formation  of  mcuous  channels  of  various  lengths.  These 
mucous  channels  may  extend  to  a  considerable  length,  and 
their  most  common  course  is  toward  the  connective  tissue 
between  the  mucous  and  muscular  layers  of  the  rectum, 
thence  downward  to  the  anus.  Here,  the  parts  being  more 
firm,  their  onward  progress  is  deflected,  and  again  following 
the  course  of  least  obstruction,  they  burrow  downward  and 
under  the  skin  about  the  anus  and  buttocks,  forward  to  the 
perineum  and  scrotum,  and  backward  into  the  space 
between  the  rectum  and  coccyx.  The  latter  space  is  a 
favorate  spot  for  the  establishment  of  mucous  channels,  as 
the  tissues  therein  are  peculiarly  adapted  for  its  invasion. 
I  have  seen  demonstrated  by  Dr.  A.  B.  Jamison  channels 
running  from  some  point  near  the  anus  directly  upward  for 
6  inches,  or  from  7  to  10  inches  directly  backward  over  the 
coccyx,  or  forward  along  the  perineal  raphe,  or  from  the 
perineum  directly  upward  and  ending  over  the  pubic  bone. 
These  channels  are  a  pathologic  entity,  and  can  be  demon- 
strated. The  mucous  pouches  or  sacs  are  most  numerous  in 
that  portion  termed  the  "pile-bearing"  area,  and  this  sac- 
culated condition  of  the  parts  has  much  to  do  with  the  pro- 
duction of  hemorrhoids. 

The  external  effect  of  this  exudate  is  to  render  the  integu- 
ment about  the  anus  puffy  and  hypertrophied,  to  cause 
dark  and  excoriated  spots,  and  sometimes  the  exudate  oozes 
through  the  skin  itself,  producing  that  annoying  moisture 
of  the  parts  which  some  superficial  observers  call  "per- 
spiration." 

Diagnosis  of  Chronic  Proctitis  and  Periproctitis. — The 
symptoms  manifested  are  those  of  inflammation  in  the 
rectum,  but  it  seems  that  in  this  location  rather  extensive 
pathologic    changes    can    take    place    before    the    patient 


MUCOUS    CHANNELS 


499 


Fig.   73. — Radiograph  (rear  view)  showing  speculum  in  rectum  and  probes  in 
numerous  mucous  channels  in  peri-rectal  spaces.     (Dr.  A.  B.  Jamison.) 


MUCOUS    CHANNELS 


501 


Fig.  74. — Diagrammatic  illustration  showing  subtegumentary  channels  as 
found  in  chronic  proctitis.  (Albright.) 
The  dotted  lines  indicate  the  locations  in  which  these  sinuses  are  most 
frequently  found.  Posteriorly,  a  branch  from  a  tract  running  directly  over  the 
coccyx  will  be  seen  extending  toward  the  right;  on  the  right,  a  sinus  coursing 
backward  from  an  accumulation  of  sero-mucous  exudate  situated  anterior  to  the 
rectum,  from  which  the  branch  to  the  scrotum  also  arises;  on  the  left,  a  channel 
is  observed  invading  the  subtegumentary  tissues  of  the  buttock.  The  incisions 
shown,  both  anterior  and  posterior  to  the  anus,  indicate  the  points  at  which  the 
first  incisions  are  usually  made.  From  these  the  various  channels  can  be 
located  and  the  proper  treatment  applied.  This  drawing  is  purely  diagram- 
matic, and  is  intended  as  an  aid  to  the  reader  in  forming  a  clear  idea  of  the 
subject.  All  the  channels  shown  are  not  supposed  to  exist  in  a  single  individual, 
neither  are  those  shown  the  only  directions  in  which  the  exudate  may  course. 


MUCOUS    CHANNELS 


503 


Fig.  75. — Radiograph  (side  view)  showing  speculum  in  rectum,  and  probes  in 
numerous  mucous  channels  in  perirectal  spaces.     (Dr.  A.  B.  Jamison.) 


MUCOUS    CHANNELS 


505 


Fig.  76. — Radiograph  showing  destruction  of  perirectal  tissues,  cavity,  and 
channel.  Metal  syringe  in  rectum.  A  marks  approximate  location  of  the 
anus.     (Albright.) 


TREATMENT    OF    PROCTITIS  507 

realizes  his  true  condition;  in  other  words  a  chronic  proc- 
titis may  exist  for  several  years  before  the  inflammatory 
process  will  cause  burning  and  discomfort  enough  to 
demand  active  treatment.  During  this  time  incessant 
impairment  of  the  function  and  structure  of  the  anal  canal 
and  rectum  is  going  on.  In  various  spots  about  the  anus 
and  buttocks  the  patient  will  complain  of  hot  and  sore 
spots,  which  indicate  the  location  of  channels  or  small 
reservoirs  near  the  surface,  and  serve  as  guides  for  beginning 
treatment. 

Mucus  is  always  found  in  the  rectum,  unless  the  inflam- 
mation has  become  localized  in  the  perirectal  structures,  or 
atrophy  has  taken  place.  The  anal  orifice  is  frequently 
constricted,  constipation  is  nearly  always  present,  though 
occasional  spells  of  diarrhea  supervene. 

Secondary  symptoms  are  presented  as  pruritus  ani, 
hemorrhoids,  and  anal  fissure,  and  those  who  have  been 
taught  otherwise  will  find  this  statement  correct  after  care- 
ful investigation. 

Treatment  of  Chronic  Proctitis  and  Periproctitis. — This 
requires  patience,  perseverance,  and  co-operation  on  the 
part  of  the  sufferer.  Daily  irrigation  with  water  heated  to 
110°  F.  (Jamison  and  Albright  advise  120)  is  indispensable. 
This  irrigation  should  be  continued  from  one-half  to  one 
hour  without  interruption,  and  to  the  hot  water  may  be 
added  sodium  borate,  boric  acid,  potassium  chlorate,  or 
magnesium  sulphate.  One  or  2  per  cent,  strength  of  these 
medicaments  is  sufficient.  To  the  last  part  of  the  irriga- 
tion there  may  be  added  with  comfort  to  the  patient  a 
little  oil  of  cajeput,  spruce,  or  cedar.  Following  this  may 
be  made  an  injection  of  warm  refined  cotton-seed  oil  (2 
or  3  ounces)  which  will  not  only  sooth  the  inflamed  parts, 
but  will  soften  and  bring  down  any  hard  scybalas  that  may 
have  found  lodgment  higher  up  in  the  gut.  If  the  patient 
can  successfully  inject  and  hold  it,  this  oil  is  best  put  in  at 
night  and  retained  until  the  following  morning. 


5o8  DUODENAL   ULCER — INTESTINAL    ULCERS 

Methods  of  thorough  irrigation  have  been  covered  in  a 
previous  chapter. 

Local  Treatment. — This  includes  a  certain  amount  of 
minor  surgery  in  that  the  sinuses  or  mucous  channels 
must  be  evacuated,  irrigated,  and  obliterated.  Having 
located  the  itching  or  irritated  spot,  a  local  anesthetic  is 
injected  into  the  skin  and  underlying  tissues  at  a  point 
midway  between  the  anus  and  coccyx,  after  which  an 
incision  about  i  inch  in  length  is  made  directly  inw^d, 
enlarging  the  opening  forward  and  backward  as  far  as  the 
anesthetic  effect  extends.  Often  a  considerable  cavity  is 
found  just  beneath  the  superficial  integument.  After 
entering,  a  careful  examination  is  made  with  a  thin  silver 
probe,  and  in  nearly  all  of  these  cases  one  or  more  sinuses 
will  be  found  leading  to  a  cavernous  reservoir  4  or  6  inches 
up.  The  channels  in  the  anterior  parts  will  be  found  to 
best  advantage  after  an  opening  is  made  into  the  perineum 
similar  to  that  made  posterior  to  the  rectum.  Channels 
running  beneath  the  integument,  when  once  located,  are 
easily  followed.  After  the  principal  channels  have  been 
discovered,  an  opening  large  enough  to  admit  an  irrigating 
tube  should  be  made,  and  it  will  be  generally  found  that  the 
opening  up  of  these  channels  and  sacs  causes  but  little 
shock  or  discomfort.  Patients  can  nearly  always  leave  the 
office  and  pursue  their  usual  vocations  with  but  small  in- 
convenience. 

The  irrigation  should  be  carried  out  with  a  solution  of 
phenol,  I  or  2  drams  to  the  pint  of  water,  permanganate  of 
potash,  15  grains  to  the  pint,  or  nitrate  of  silver,  when  the 
granulations  do  not  heal  satisfactorily. 

The  irrigation  should  be  carried  out  daily,  and  when  the 
patient  cannot  come  to  the  physician's  office,  some  member 
of  the  family  should  be  instructed  in  its  application.  After 
thorough  irrigation,  the  wound  is  packed  with  plain  gauze, 
which  should  be  removed  about  thirty  minutes  before  the 
next  irrigation,  for  it  will  aid  matters  to  let  the  patient 
enjoy  a  hot  sitz-bath  a  short  while  before  each  irrigation. 


SUBTEGUMENTARY    CAVITIES 


509 


Fig.  77. — Radiograph  showing  subtegumentary  cavity  in  the  buttock, 
due  to  the  burrowing  of  the  acrid  exudate  resulting  from  proctitis.  Complete 
destruction  of  the  areolar  tissue  in  the  post-rectal  space,  and  a  submucous 
sinus.     (Albright.) 


ULCERATION   OF   RECTUM 


Sii 


The  physician  should  seek,  should  open  up,  and  should 
irrigate  each  channel,  and  in  this  way,  after  a  time  condi- 
tions will  regain  their  wonted  health,  and,  the  patient'  will 
experience  great  comfort. 


Fig.  78. — Jamison's  sitz-bath  pan. 

Ulceration  of  the  Rectum. — Ulcers  in  this  part  of  the 
intestinal  canal  are  of  the  most  varying  depth  and  size,  from 
superficial  erosions  to  deep-seated  ulcerations  the  size  of  a 
dime.  Sometimes  the  mucous  channels  previously  spoken 
of  break  down  and  form  deep  ulcerations,  but  generally  the 
origin  lies  in  infections  from  gonorrhea,  syphilis,  tuberculo- 
sis, dysentery,  typhoid  fever,  pyemia,  etc.  Gonorrheal 
infections  are  most  frequent  in  women  through  taking 
enemata  with  an  infected  syringe. 

Diagnosis. — This  may  be  made  by  careful  examination  of 
the  rectal  walls.  When  they  are  low  down,  they  may  be 
easily  seen,  but  when  high  up  in  the  rectum  a  rectoscope  or 
sigmoidoscope  is  required.  The  manipulation  of  these 
instruments  has  been  described. 

Treatment. — The  ulcers  man  be  "touched"  with  pure 
phenol,  or  silver  nitrate,  care  being  exercised  to  apply  the 
cauteiant  only  to  the  actual  ulceration.  If  a  rather  large 
surface  is  to  be  treated,  a  solution  of  silver  nitrate,  40 
grains  to  the  ounce,  is  preferable.  For  the  accompanying 
proctitis  the  irrigations  and  ointments  previously  described 
will  be  appropriate. 

Stenosis  of  the  Intestinal  Canal. — This  is  brought  on  by 
the  same  causes,  i.e.,  ulcers,  infections,  etc.,  as  cavise  steno- 


512  DUODENAL   ULCER — INTESTINAL    ULCERS 

sis  in  the  other  regions  of  the  intestine.  As  a  sequel  to 
stenosis,  there  are  dilatations  above  the  stenoses,  and  the 
various  symptoms  of  intestinal  stasis,  obstruction,  and  dila- 
tation are  found. 

Diagnosis. — A  stenosis  of  moderate  constriction  may 
exist  a  long  time  without  giving  rise  to  any  marked  symp- 
toms, for  liquid  feces  may  pass  by  some  effort,  and  a  com- 
pensatory hypertrophy  of  the  intestinal  muscles  tends  to 
force  the  fecal  current  by  the  stricture.  Even  a  stenosis  of 
the  sigmoid  may  be  compensated  for  a  while,  but  eventually 
the  patient  will  feel  griping  pains,  tension  in  the  abdomen, 
a  sense  of  obstruction  at  some  point,  which  he  can  note 
when  it  is  overcome,  and  recurrent  attacks  of  colic  which 
disappear  when  the  bowels  are  freely  emptied. 

Sometimes  the  patient  or  the  physician  will  observe  that 
the  stool  is  of  small  caliber,  and  made  up  of  irregular  or 
broken  fragments  of  fecal  matter.  Another  annoying 
symptom  is  gaseous  distention,  which  "balloons"  the  abdo- 
men, and  restless  and  easily  felt  tonic  contractions  of  the 
intestine  may  be  noted  above  the  stenosis. 

"Sometimes,"  says  Nothnagel,  "the  diagnosis  of  stenosis 
can  be  made  with  absolute  certainty,  and  sometimes  this  is 
impossible;  between  these  extremes  there  exist  many  cases 
in  which  the  diagnosis  can  be  made  with  greater  or  less 
probability." 

Examination  by  the  X-rays  after  a  bismuth  test-meal  is 
the  most  certain  means  of  diagnosing  these  cases,  and  when 
the  technic  is  correct  and  expert,  both  stenoses  and  dilata- 
tions may  generally  be  located  and  delimited  with  absolute 
confidence. 

Treatment. — Much  may  be  done  by  medical  means,  and 
surgery  should  not  be  resorted  to  unless  there  is  malignancy, 
or  the  obstruction  renders  the  patient's  life  a  burden,  or 
closure  of  the  canal  is  complete. 

The  diet  should  be  bulky,  with  much  cellulose  and  much 
fat.  In  addition  agar  agar  should  be  taken  with  the  food 
several  times  daily.     Much  water  should  be  drunk,  and 


MESENTERIC   BANDS 


513 


every  means  should  be  employed  to  stretch  the  lumen  of 
the  canal  and  to  keep  the  fecal  current  moving  onward. 
The  different  oils  as  olive  oil,  cotton-seed  oil,  and  at  times 
castor  oil  should  be  given  to  keep  the  intestinal  walls  well 
lubricated.  The  liquid  albolene  and  liquid  paraffin  are 
most  useful,  and  the  case  of  Dr.  Bassler  has  been  mentioned, 
in( -which  8  ounces  of  liquid  paraffin  were  required  to  move 
the  bowels.  These  oily  preparations  should  be  given  in 
sufficient  quantities  to  get  results,  and  the  physician  should 


Fig.  79. — Mesenteric  bands  on  under  surface  of  sigmoid. 


not  hesitate  to  push  them,  otherwise  the  obstruction  may  be- 
come insuperable,  and  the  surgeon  will  need  to  be  called  in. 

Many  times  the  obstructions  are  the  result  of  kinks  or 
adhesive  bands,  and  the  surgeons  are  now  investigating 
with  much  interest  the  formation  of  these  constricting 
bands,  and  attempting  to  decide  whether  their  origin  is 
pathologic  or  physiologic.  The  decision  has  not  yet  been 
reached. 

By  the  use  of  the  foregoing  methods  of  treatment,  and 
never  allowing  the  bowels  to  fail  of  daily  evacuation,  many 
cases  of  extensive  and  tight  intestinal  constriction  may  live 
for  years  in  comparative  comfort. 

33 


514 


DUODENAL   ULCER — INTESTINAL    ULCERS 


The  case  is  mentioned  in  a  previous  chapter  where  a 
woman  had  multiple  strictures  extending  over  several  feet 
of  her  small  intestine— so  extensive,  in  fact,  that  the  sur- 
geon, on  entering  the  abdomen,  could  do  nothing.  This 
woman,  after  two  years,  is  living  and  in  fairly  good  health, 
though  she  has  to  diligently  carry  out  the  instructions. 

Malignant  neoplasms  of  the  intestines  or  rectum  are 
purely  surgical  conditions,  and  call  for  no  special  discussion 
in  this  work. 


Fig.  8o. — Lanis  kink  of  ileum. 


Apart  from  surgical  care,  however,  the  same  general 
principles  apply  as  in  carcinoma  ventriculi,  namely,  seda- 
tives for  the  pain,  bland,  nutritious,  and  easily  digested 
diet,  appropriate  digestives,  and  all  the  cheering  psycho- 
therapy that  can  be  afforded.  In  such  cases  I  may  be 
excused  for  repeating  the  phrase,  "though  little  can  be 
done  for  the  disease,  much  can  be  done  for  the  patient." 


CHAPTER  XXI 
DIARRHEA  AND  DYSENTERY 

Clinically,  diarrhea  may  be  defined  as  abnormal  rapidity 
of  intestinal  peristalsis,  accompanied  by  frequent  evacua- 
tion of  the  bowel  contents,  which  are  too  liquid  or  watery 
in  character. 

The  term  "loose  bowels"  is  a  comparative  one,  for  some 
there  are  whose  bowels  normally  move  two  or  three  times 
daily,  while  others  of  a  constipated  habit  would  be  in  a 
diarrheal  condition  were  the  intestines  to  be  evacuated 
twice  in  twenty-four  hours. 

Diarrheal  stools  are  caused  by  the  excess  of  water  in  the 
feces,  and  may  be  due  to  the  liquid  contents  of  the  small 
intestine  being  so  rapidly  hurried  into  the  colon  that  little 
absorption  can  take  place  in  the  small  intestine.  The  free 
transudation  of  water  from  the  blood-vessels  or  glands  may 
also  be  a  factor.  At  times  increased  peristalsis  is  the  only 
cause,  and  both  the  large  and  small  intestine  may  be 
involved,  while  no  organic  lesions  are  present.  There  are 
numerous  ways  by  which  increased  intestinal  peristalsis 
may  be  originated.  In  the  majority  of  instances  it  is  the 
result  of  anatomic  changes  caused  by  disease,  as  intestinal 
catarrh,  ulcers  from  typhoid,  etc.  Again  it  may  be  caused 
by  irritability  of  nerves  of  the  intestinal  walls,  or  it  may  be 
due  to  a  central  lesion  of  the  nervous  system.  In  consider- 
ing a  diarrhea  it  is  important  to  know  whether  it  is  produced 
by  abnormal  exudation  with  increased  peristalsis  of  the 
large  intestine;  or  whether  the  peristalsis  of  the  small 
intestine  is  increased,  as  in  the  latter  unchanged  digestive 
fluids  and  large  amounts  of  undigested  food-stuffs  may  be 
hurried  through  the  small  gut  resulting  in  great  damage  to 
the  nutrition. 

SIS 


5l6  DIARRHEA  AND  DYSENTERY 

The  type  of  diarrhea  brought  about  by  intestinal  ulcer- 
ation is  discussed  elsewhere.  This  form  is  secondary  to 
the  anatomic  changes  and  should  be  looked  upon  as  an 
incident,  wherein,  if  the  real  cause  is  controlled  or  cured, 
the  diarrhea  quickly  ceases. 

The  type  of  diarrhea  which  will  now  be  covered  is  that 
due  to  irritation  from  substances  contained  in  the  bowel  con- 
tents, in  which  no  intestinal  lesions  are  originally  present. 
This  type  may  be  classified  as  follows : 
Irritative  diarrhea  from  bowel  contents,  as  diarrhea 
dyspeptica  from  the  presence  of  undigested  food;  diarrhea 
gastrica  (gastrogenic  diarrhea)  in  which  the  stomach  per- 
mits undigested  food  to  escape  into  the  small  intestine; 
diarrhea  stercoralis,  or  that  produced  by  irritating  fecal 
matter;  diarrhea  entozoica,  or  that  produced  by  intestinal 
parasites;  diarrhea  from  irritants  transmitted  in  the  blood, 
as  uremia;  and  nervous  diarrhea. 

Diarrhea  Cathartica. — This  term,  as  used  by  Nothnagel, 
is  intended  to  mean  undue  bowel  movements  brought  about 
by  the  ingestion  of  strong  cathartic  medicines.  In  many 
instances  a  catarrhal  condition  of  the  intestinal  mucosa 
may  be  set  up  by  the  unwise  or  prolonged  use  of  cathartics, 
and  a  severe  diarrhea  may  ensue. 

Diarrhea  Dyspeptica. — This  is  probably  the.  most  com- 
mon, and  is  produced  by  irritating  or  indigestible  food,  as 
fresh  or  unripe  fruit,  cucumbers,  pickles,  etc.  There  is 
great  variation  as  to  susceptibility,  for  certain  articles  that 
may  set  up  a  violent  diarrhea  in  some  individuals  may 
either  cause  no  disturbance,  or  even  constipate  others; 
while  some  individuals  can  eat  with  impunity  certain  arti- 
cles under  favorable  circumstances,  while  under  other  cir- 
cumstances the  same  articles  will  set  up  a  diarrhea. 

The  food  may  contain  pathogenic  organisms  when 
ingested,  or  may  ferment  and  spoil  after  entering  the  intes- 
tines. These  are  the  conditions  under  which  are  observed 
the  various  food  poisonings,  and  in  which  important  con- 
siderations, legal  and  otherwise,  may  be  involved. 


TYPES    OF   DIARRHEA  517 

Diarrhea  dyspeptica,  uncontrolled,  may  merge  into  the 
chronic  catarrhal  form. 

Diarrhea  Gastrica,  or  Gastrogenic  Diarrhea. — A  number 
of  years  ago  Einhorn  called  attention  to  cases  of  diarrhea, 
in  which  the  stomach  was  entirely  at  fault.  In  the  major- 
ity of  instances  there  was  a  marked  diminution  or  entire 
absence  of  hydrochloric  acid  in  the  stomach,  and  with  a 
patulous  pyloric  outlet,  the  food  was  thrown  into  the  small 
intestine  in  an  unprepared  condition. 

In  such  cases  there  are  flatulence,  borborygmus,  and  col- 
icky pains,  with  a  tendency  to  bowel  movements  soon  after 
meals.    This  condition,  too,  may  develop  intestinal  catarrh. 

Diarrhea  Stercoralis. — This  is  an  intermittent  diarrhea 
noted  in  constipated  persons,  in  which  after  a  period  of 
constipation,  there  sets  in  a  short  but  painful  diarrhea, 
accompanied  by  cramps,  great  flatulence,  and  the  passage 
of  hardened  lumps  of  feces.  After  the  bowels  are  thor- 
oughly emptied,  relief  is  obtained. 

Diarrhea  Entozoica. — This  is  the  form  brought  on  by  in- 
testinal parasites,  as  the  tapeworm  or  others.  Like  other 
forms  of  diarrhea,  there  are  at  first  no  organic  lesions  present, 
but  these  may  appear  after  long-continued  irritation. 

A  very  marked  and  sometimes  intractable  diarrhea  may 
be  produced  by  irritants  in  the  blood,  as  the  diarrhea  of 
septicemia,  nephritis,  diabetes,  cholera,  etc. 

In  this  class  may  be  properly  included  the  "compensa- 
tory diarrheas,"  being  that  form  of  diarrhea  in  which  the 
toxic  products  of  catabolism  are  simply  washed  out,  with 
neither  material  harm  to  the  bowel,  nor  systemic  shock. 

Dr.  Henrich  Stern  classifies  the  types  of  compensatory 
diarrhea  as  (i)  diarrhea  concomitant  with  deficient  or 
perverse  catabolic  processes;  (2)  diarrhea  which  is  the 
consequence  of  functional  or  structural  disease  of  certain 
excretory  organs;  (3)  diarrhea  occurring  during  the  pe- 
riod of  systemic  physiologic  decline.  As  illustrative  of  the 
first  type  may  be  mentioned  the  diarrheas  of  gout,  Addi- 
son's disease,  diabetes,  goiter,  and  pellagra.     The  second 


5l8  DIARRHEA  AND  DYSENTERY 

form  of  compensatory  diarrhea  may  present  itself  as  a 
concomitant  of  impaired  renal  function,  or  as  the  result  of 
extensive  burns  over  the  abdomen. 

That  certain  diarrheas,  not  exhausting,  but  rather 
grateful  in  their  effects,  are  not  infrequent  in  old  people, 
will  be  noted  by  all  careful  observers,  and  I  have  under 
treatment  at  present  a  hale  old  gentleman,  who  welcomes 
his  fortnightly  diarrhea  as  a  salutary  visitation.  In  these 
forms  of  compensatory  diarrhea  the  discharges  from  the 
bowel  consist  in  the  main  of  incompletely  or  perversely 
catabolized  substances,  or  catabolic  products  normally 
excreted  by  other  emunctories. 

This  type  may  also  represent  certain  toxic  states  of  the 
blood  with  secondary  elimination  of  toxins  through  the 
intestinal  mucous  membrane.  We  should  not  forget, 
however,  that  it  is  possible  for  an  irritative  diarrhea  to  occur 
simultaneous  with  one  of  a  compensatory  nature,  or  that 
secondary  inflammatory  lesions  of  the  intestinal  mucosa 
may  merge  this  beneficial  drainage  into  an  exhausting 
process ;  and  it  can  be  readily  understood  how  the  passage 
of  these  toxins  from  the  blood,  plus  other  excrementitious 
substances,  may  intensify  the  diarrhea,  and  transform  the 
disturbance  into  one  of  a  non-compensatory  character. 

Further  studies,  since  the  compensatory  character  of 
pellagrous  diarrhea  was  advanced  by  the  writer  four  years 
ago,  have  tended  to  prove  the  truth  of  that  contention. 
The  early  diarrhea  in  this  disease  is  of  central  origin,  though 
the  later  manifestations  may,  and  generally  do,  become 
irritative.  Another  probable  cause  of  the  diarrhea  lies  in 
the  great  diminution  of  tegumentary  excretory  power 
entailed  by  the  dry  and  scaly  skin,  which  would  demand  a 
vicarious  activity  of  both  the  bowels  and  kidneys.  The 
resident  physician  of  one  of  the  local  sanatoria  has  reported 
to  me  a  recent  case  of  pellagra  coming  under  his  observa- 
tion, where  the  patient  seemed  to  be  progressing  favorably, 
but  on  checking  suddenly  his  rather  profuse  diarrhea,  he 
went  into  coma,  dying  in  about  twenty-four  hours. 


COMPENSATORY   DIARRHEA  519 

It  has  been  observed  that  within  two  days  after  a  burn, 
not  necessarily  deep,  but  covering  an  extensive  area,  a 
very  watery  diarrhea  often  occurs,  followed  by  an  improve- 
ment in  the  shock  and  clearing  up  of  the  mental  hebetude  or 
coma.  This  is  evidently  a  vicarious  elimination  of  auto- 
toxicoses,  and  it  is  probable  that,  in  addition  to  the  curtailed 
activity  of  the  skin,  there  are  also  some  poisonous  gases 
generated  in  the  body,  which  are  discharged  through  the 
bowels  along  with  other  catabolic  products.  The  colli- 
quative diarrhea  supervening  after  a  long  confinement  from 
a  burn,  resulting  from  both  systemic  exhaustion  and  ulcer- 
ated intestines,  is  generally  a  terminal  symptom  and  not  at 
all  compensatory. 

In  uremic  intoxication  we  probably  note  the  most  fre- 
quent compensatory  diarrhea,  though  this  symptom  is 
hardly  as  common  as  the  vomiting.  As  far  back  as  1859 
Treitz  claimed  that  the  intestinal  irritation  occurring  in  the 
course  of  nephritis  was  produced  by  ammonium  carbonate 
formed  in  the  intestinal  tract  by  the  urea  excreted  into  it. 
This  irritation  may  progress  until  catarrhal  enteritis,  and, 
later  on,  uremic  ulcers  are  formed,  provoking  continuous 
intestinal  disturbances  not  compensatory  in  their  nature. 
The  diarrhea  in  uremic  conditions,  therefore,  where  there  are 
no  decided  changes  in  the  intestines,  may  generally  be 
regarded  as  compensatory,  and  treated  as  such. 

In  old  people,  especially  women  past  the  climacteric,  we 
notice  occasional  attacks  of  diarrhea,  apparently  unpro- 
voked by  dietary  indiscretions  or  atmospheric  changes, 
brief,  painless,  and  followed  by  no  exhaustion.  This  peri- 
odical washing  out  of  catabolic  products  is  probably  due 
to  the  fact  that  the  tegumentary  eliminative  functions  in 
the  old  of  both  sexes  are  incomplete,  while  in  some  women 
the  body  continues  to  require  that  occasional  readjustment 
formerly  afforded  by  the  menstrual  flow. 

Diarrhea  Nervosa  (Nervous  Diarrhea)  .^ — This  depends 
on  nervous  or  psychic  disturbances,  without  any  morbid 
changes  in  the  walls  of  the  intestines.     It  is  entirely  com- 


520  DIARRHEA   AND   DYSENTERY 

patible  with  this  type  for  a  marked  diarrheal  discharge  to 
be  present,  while  no  impairment  of  the  digestion  is  felt  by 
the  patient. 

True  nervous  diarrhea  may  originate  from  excessive 
stimulation  of  the  nerves  governing  peristalsis,  or  from  the 
transudation  of  great  quantities  of  serous  material  into  the 
bowel  brought  on  by  nervous  influences.  In  many  cases 
both  conditions  obtain.  In  some  instances  the  stimulus 
may  originate  in  the  nerve- centers,  and,  being  transmitted 
through  the  fibers  of  the  vagus,  sympathetic,  or  splanchnic 
nerves,  may  thus  reach  the  intestinal  ganglia. 

Examples  of  nervous  or  psychic  diarrhea  are  easy  to  find, 
and  can  be  traced  directly  to  some  emotion,  as  fright,  shock, 
or  disgust,  which  send  their  impulse  to  the  brain  centers  and 
from  thence  reach  the  intestines. 

Nothnagel  reports  instances  of  chronic  nervous  diarrhea 
in  persons  who  are  attacked  with  gurgling,  abdominal  pain, 
tenesmus,  and  loose  evacuations  as  soon  as  they  find  they 
can  secure  no  access  to  a  convenient  toilet ;  while  in  others 
the  sight  of  a  toilet  produces  this  symptom.  Some  patients 
may  have  attacks  at  definite  hours,  without  any  relation 
to  surrounding  conditions. 

With  some  people  a  regular  syndrome  of  symptoms  may 
precede  the  diarrhea,  as  vertigo,  giddiness,  congestion  of 
the  head,  reddening  of  the  face,  hot  flushes  over  the  body, 
fear,  oppression,  palpitation,  and  rapid  breathing;  and, 
strange  to  say,  these  distressing  manifestations  quickly 
disappear  after  several  copious  diarrheal  movements  of 
the  bowels. 

In  a  diarrheal  attack  the  number  of  stools  may  vary  from 
two  to  even  fifteen,  and  consist  of  liquid  with  little  if  any 
mucus.  Generally  the  first  movement  is  comparatively 
normal,  the  next  mushy,  and  the  rest  watery.  This  form 
of  diarrhea  is  found  in  hysteria,  neurasthenia  and  psychas- 
thenia,  and  even  in  healthy  people  after  a  nervous  shock. 
The  instance  of  soldiers  suffering  from  nervous  diarrhea 
when  they  first  "face  gunpowder"  is  well  known. 


TREATMENT   OF   DIARRHEA  $21 

Charcot  describes  attacks  with  tabes  (intestinal  crises) 
much  in  character  like  the  gastric  crises;  and  Peyer  men- 
tions a  reflex  form  of  nervous  diarrhea  concomitant  with 
abnormal  conditions  of  the  genitourinary  tract,  as  from 
uterine  catarrh,  nocturnal  emissions,  spermatorrhea,  and 
sexual  excesses.  Fischl  reports  a  stubborn  case  of  diarrhea, 
resisting  all  treatment,  cured  by  replacing  a  reflexed  uterus. 

TREATMENT  OF  DIARRHEA 

I  shall  not  attempt  to  specifically  consider  the  treatment 
of  a  chronic  diarrhea  that  is  caused  by  enteritis,  colitis, 
deep-seated  ulceration,  tuberculosis  of  the  bowels,  or  that 
produced  by  or  concomitant  with  chronic  organic  diseases. 

A  chronic  looseness  of  the  bowels  cannot  be  successfully 
treated  until  its  cause  has  been  determined  and  it  has  also 
been  determined  whether  there  is  really  a  condition  of 
diarrhea.  As  well  said  by  Dr.  Blackader,  formed  move- 
ments of  the  bowels,  two  or  three  daily,  in  a  person  who  has 
long  had  this  habit  cannot  be  considered  pathologic,  but 
unformed,  watery  movements,  even  if  not  more  than  one  or 
two  a  day,  must  be  considered  abnormal.  Such  a  character 
of  the  movements  may  be  brought  about  by  a  disordered 
normal  function  or  by  an  actual  pathologic  condition. 

Diarrhea  brought  on  by  the  unwise  use  of  laxative  drugs 
or  waters  can  be  controlled  best  by  tincture  of  opium  and 
bismuth,  with  rest  in  bed  and  hot  applications  to  the  abdo- 
men. It  may  be  laid  down  as  a  general  principle  that,  as 
exercise  stimulates  peristalsis,  quietude,  both  physical  and 
mental,  will  soothe  troubled  peristalsis. 

A  good  general  rule  in  administering  astringent  remedies 
for  diarrhea  is  to  direct  a  dose  "after  each  loose  action," 
but  generally  not  nearer  together  than  one  hour.  In  this 
manner  as  the  peristalsis  subsides  the  medicine  is  given  less 
frequently,  and  the  danger  of  "binding  up"  the  bowels  too 
tightly  is  avoided. 


522  DIARRHEA   AND   DYSENTERY 

With  either  dyspeptic  or  stercoral  diarrhea  the  first 
requisite  is  the  removal  of  the  offending  and  irritating 
material  from  the  digestive  canal.  To  accomplish  this  the 
most  efficient  laxatives  are  Epsom,  Rochelle,  or  Sprudel 
salts,  or  castor  oil.  After  the  bowels  are  well  emptied  by 
two  or  three  copious  movements  unaccompanied  by  grip- 
ing, an  astringent  may  be  given  after  each  loose  movement 
until  the  bowels  are  regulated.  Occasionally  intestinal 
irrigation  is  indicated  in  these  types. 

For  gastrogenic  diarrhea,  or  that  produced  by  faulty 
stomach  digestion,  both  the  diet  and  the  deficient  gas- 
tric juices  should  be  considered.  Chiefly  finely  divided 
starchy  foods  are  indicated,  and  dilute  hydrochloric  acid 
with  pepsin  should  be  given  after  meals.  The  actual 
diarrhea  demands  the  same  medication  as  other  forms. 

The  physician's  viewpoint  toward  the  various  compen- 
satory diarrheas  should  be  different,  and  as  a  factor  for  good 
its  chronicity  must  often  be  welcomed.  To  a  certain 
extent  it  fills  the  same  useful  place  as  the  safety  valve  on  a 
steam  engine,  "popping  off"  when  the  pressure  becomes 
dangerously  high.  When  in  the  several  conditions  men- 
tioned, this  bodily  safety  valve  shows  its  ability  to  "pop 
off"  at  intervals,  the  probability  of  a  sudden  fatal  termina- 
tion is  much  lessened.  As  a  general  rule,  when  the  medical 
attendant  feels  that  this  compensatory  process  is  well  estab- 
lished, he  may  venture  a  much  more  favorable  prognosis 
as  to  the  danger  of  fatal  dyspnea,  convulsions  or  coma,  and 
may  hold  out  to  his  patient  the  hope  of  a  material  prolon- 
gation of  life.  Therefore,  unless  the  diarrhea  shows  a 
marked  tendency  to  set  up  acute  irritation  or  ulceration,  or 
becomes  decidedly  exhausting  in  its  nature,  no  therapeutic 
measures  to  check  it  should  be  employed. 

The  various  astringent  prescriptions  suitable  for  acute 
diarrhea  are  laid  down  in  the  chapter  on  drug  thera- 
peutics. 

Chronic  Diarrhea. — Chronic  looseness  of  the  bowels 
require  in   some  particulars   different   management^  from 


CHRONIC    DIARRHEA  523 

the  acute,  and  this  management,  as  classified  by  Black- 
ader,  may  be  considered  as  (i)  physical,  (2)  dietetic,  (3) 
medicinal. 

Among  the  physical  requirements  may  be  mentioned 
rest,  either  absolute  or  at  least  a  while  after  each  meal.  A 
change  of  climate,  especially  from  a  warm  to  a  cool  climate 
is  often  followed  by  a  complete  cessation  of  the  diarrheal 
symptoms.  With  this  change  there  may  also  come  relief 
from  business  cares  or  household  worries,  and  in  some 
instances  this  relief  can  only  be  attained  through  sanator- 
ium treatment. 

Other  helpful  physical  methods  are  included  in  baths, 
which  promote  normal  activity  of  the  skin,  electricity, 
massage,  and  passive  movements,  which  may  later  be 
followed  by  those  more  active.  The  exercises  are  indicated 
principally  in  those  who  have  led  a  sedentary  life.  This 
form  of  treatment  is  specially  beneficial  for  the  nervous 
forms  of  diarrhea. 

Diet. — This  will  often  call  for  a  careful  study  of  individual 
peculiarities,  as  well  as  the  efficiency  of  the  digestive 
juices,  and  then  on  limited  diets,  changed  from  time  to 
time,  the  physician  will  determine  that  there  are  one  or 
more  articles  of  food  which  increase  indigestion  and  pro- 
mote looseness  of  the  bowels.  Such  articles  of  food  must, 
of  course,  be  temporarily  at  least  prohibited.  However,  it 
is  often  best  to  put  the  patient  on  an  absolute  milk  diet  for  a 
week,  and  then  gradually  try  the  additions  of  different  foods 
to  the  dietary.  Occasionally  a  strictly  milk  diet  will  not 
be  tolerated,  and  it  may  be  found  necessary  to  add  an  alkali 
to  each  glass  of  milk,  as  lime  water  or  milk  of  bismuth. 
Boiling  the  milk  may  make  it  agree,  or  it  may  be  necessary 
to  peptonize  it,  the  latter  being  rarely  needed.  If  the  patient 
is  an  adult  and  is  placed  on  an  absolute  milk  diet,  he  should 
not  attempt  to  work.  As  before  intimated,  complete 
rest  in  bed  for  one  or  two  weeks,  on  a  corrected  diet,  should 
materially  start  the  sufferer  on  the  road  to  recovery.  The 
first  addition  to  the  milk  diet  should  be  toast,  eggs,  and 


524  DIARRHEA  AND  DYSENTERY 

raw  or  scraped  beef,  or,  if  uncooked  meat  is  repulsive  to  the 
patient,  the  chopped  beef  may  be  slightly  broiled.  The 
future  increase  in  the  diet  should  be  carefully  suited  to  the 
individual,  avoiding  for  quite  a  while  those  foods  contain- 
ing an  abundance  of  cellulose  or  irritating  residue. 

Drugs. — Perhaps  the  most  useful  of  all  drugs  in  the 
treatment  of  diarrhea  is  bismuth,  and  next  the  tannin 
preparations.     Opium,  as  a  rule,  is  not  advisable. 

The  two  methods  of  giving  bismuth  are  either  to  give 
two  large  doses  of  about  one  teaspoonful  each  day,  or  to 
give  about  5  grains  every  three  hours.  I  prefer  the  former, 
though  about  one  day  in  each  week  I  omit  it,  lest  it  form 
scybalous  masses  in  the  colon.  If  bismuth  is  long  admin- 
istered, it  may  be  best  occasionally  to  omit  it  for  four  or 
five  days,  unless  the  bowel  movements  are  free. 

The  most  eligible  form  of  tannin  seems  to  be  tannigen, 
which  may  be  given  in  doses  of  ten  or  fifteen  grains  after 
each  loose  action.  This  is  especially  serviceable  in  serous 
forms,  or  pellagrous  diarrhea,  and  may  be  given  regularly 
for  several  weeks  without  harm  or  seeming  habituation.  It 
is  claimed,  probably  with  some  justice,  that  tannigen  exerts 
no  effect  in  the  stomach,  but  produces  its  astringent  action 
throughout  the  intestinal  tract. 

The  vegetable  astringents,  as  kino,  catechu,  rhatany,  and 
others  in  that  class,  may  be  given  in  ten-  or  fifteen-drop 
doses,  either  in  water,  or  with  the  milk  of  bismuth  as  a 
vehicle. 

An  antiseptic,  such  as  phenyl  salicylate  (salol)  may  be 
given  with  benefit  in  5 -grain  doses  three  or  four  times  daily, 
unless  albumen  is  in  the  urine.  This  drug  may  also  be 
combined  with  the  bismuth. 

Occasionally  bicarbonate  of  soda  is  of  assistance,  but 
alkalies  are  seldom  indicated,  unless  in  those  rare  cases  of 
hyperacidity.  On  the  other  hand  the  dilute  hydrochloric 
acid  is  often  beneficial,  and  some  diarrheas  originating  from 
achylic  stomachs  yield  to  this  acid  alone. 

Quinin  seems  to  have  many  times  a  specific  action  in  the 


DYSENTERY  525 

intestine,  not  only  as  an  antiseptic  and  tonic,  but  really 
seems  often  to  alone  inhibit  looseness  of  the  bowels. 

As  most  of  these  patients  are,  or  later  on  become,  anemic, 
iron  is  generally  indicated  both  for  its  tonic  and  astringent 
effect.  The  most  eligible  preparations  are  the  sulphate  of 
iron  in  doses  of  3  or  4  grains  after  meals,  or  the  tincture  of 
the  chlorid  of  iron  in  doses  of  ten  to  twelve  drops  in  water 
after  meals.  When  the  latter  preparation  is  being  adminis- 
tered no  dilute  hydrochloric  acid  should  be  given,  unless 
there  is  a  marked  demand  for  acids.  Should  these  disagree, 
other  preparations  of  iron  are  available. 

DYSENTERY 

One  or  two  decades  in  the  past,  dysentery  was  recognized 
as  a  rather  common  disease,  characterized  by  frequent 
movements  of  the  bowels,  containing  mucus  mixed  with 
blood,  and  accompanied  by  griping  pains  and  rectal  tenes- 
mus, the  pathologic  lesions  on  which  these  symptoms 
depended  being  situated  chiefly  in  the  large  intestine; 
the  disease  being  regarded  chiefly  as  the  result  of  cold,  and 
the  treatment  consisting  of  the  administration  of  a  laxative 
followed  by  astringents  and  sedatives. 

At  present  it  is  known  to  be  an  infectious  disease  char- 
acterized by  specific  ulcerations  of  the  large  intestine,  and  in 
typic  acute  cases  it  gives  rise  to  bloody  mucus  or  muco- 
purulent dejections,  accompanied  by  extreme  tenesmus. 

This  disease  is  found  in  all  parts  of  the  world,  is  endemic 
and  often  epidemic.  It  is  most  common  in  warm  climates, 
as  in  the  southern  portion  of  the  United  States,  Cuba,  the 
PhiHppine  Islands,  and  along  the  southern  coast  line  of 
Asia,  Africa,  Egypt,  Mexico,  Central  and  South  America. 
It  has  been  met  with,  however,  in  cold  climates,  as  North 
Russia  and  Greenland. 

Unless  sanitary  precautions  can  be  strictly  carried  out, 
this  disease  is  the  bane  of  warfare,  and  during  the  Spanish- 
American  war  the  mortality  from  dysentery  and  typhoid 


526  DIARRHEA   AND   DYSENTERY 

was  far  in  excess  of  that  from  battle.  In  the  Boer  war  the 
EngHsh  troops  suffered  likewise. 

Dampness,  overcrowding,  and  imperfect  ventilation  pre- 
dispose to  dysentery,  and  when  a  sporadic  case  occurs,  and 
sanitary  regulations  are  poor,  infection  from  the  dejecta  can 
readily  follow,  and  an  epidemic  be  precipitated. 

In  the  Russo-Japanese  war  the  Japanese  medical  officers 
took  every  possible  sanitary  precaution,  with  the  result 
that  the  death  rate  from  typhoid  and  dysentery  was  prac- 
tically negligible,  thus  demonstrating  that  by  proper  care 
of  the  water-supply  and  proper  sanitation  epidemics  of 
dysentery  can  be  stamped  out. 

Heat  and  moisture  predispose  to  intestinal  disorders,  and 
under  such  conditions  vegetables,  fruits  or  canned  foods 
easily  deteriorate,  disturbing  the  digestion  and  rendering 
infection  easy.  Sudden  alterations  from  heat  to  cold 
or  from  dry  to  a  humid  atmosphere  also  predispose  to 
dysentery. 

No  age  nor  race  is  exempt,  but  the  poorly  nourished,  the 
old,  and  those  below  par  from  other  -causes  more  readily 
succumb  to  its  ravages.  It  is  often  prevalent  in  small 
towns  or  country  localities  where  the  water  supply  is 
dependent  on  wells  that  are  in  proximity  to  open  privies, 
stagnant  pools,  or  stables. 

Types  of  Dysentery .^ — Bacillary  dysentery  (Shiga)  or 
one  of  its  strains,  under  which  may  be  included  the  sporadic 
type  (acute  catarrhal),  and  which  probably  includes  the 
ileocolitis  of  infants. 

Amebic  dysentery,  caused  by  the  presence  in  the  intestine 
of  a  protozoon  to  which  has  been  given  the  name  ameha 
coli,  or  ameha  dysenteries.  These  cases  have  been  observed 
principally  in  tropical  climes,  and  the  synonym,  tropical 
dysentery,  would  lead  some  to  suppose  it  of  small  interest 
to  physicians  in  temperate  latitudes.  But,  since  our 
flag  has  been  planted  in  the  Philippines,  giving  rise  to  a 
constant  travel  to  and  from  those  islands ;  since  the  Panama 
canal  brings  thousands  of  our  people  who  labor  there  into 


DIAGNOSIS    OF    DYSENTERY  527 

intimate  touch  with  the  United  States;  and  also  with  the 
large  and  growing  fleet  of  fruit  vessels  plying  between  our 
shores  and  the  South  and  Central  American  countries,  the 
subject  of  amebic  dysentery  has  become  of  importance  to 
communities  far  removed  from  the  tropics. 

The  examination  of  the  stools  and  the  technic  for  dis- 
covery and  classification  of  the  amebse  have  been  thor- 
oughly discussed  in  the  chapter  upon  examination  of  feces. 

The  source  of  infection  is  chiefly  contaminated  water,  and 
green  vegetables  or  fruit.  Musgrave  has  found  the  ameba 
on  dishes  washed  in  tap  water,  on  the  surface  of  uncooked 
vegetables,  in  milk,  and  on  the  hands  of  attendants. 

That  the  ordinary  non-pathogenic  water  ameba  can  and 
does  produce  amebiasis  is  brought  out  by  Allan,  also  by 
Nichols  and  Siler  of  the  U.  S.  Army  Medical  Corps.  Allan 
believes,  in  addition,  that  the  ameba  found  in  the  soil  may 
become  pathogenic  when  taken  into  the  body.  Out  of  five 
specimens  of  earth,  taken  from  vegetable  gardens  in  Char- 
lotte, two  showed  amebae.  It  has  been  stated  by  Schaudinn 
that  amebae  occur  in  normal  stools — meaning  normal  indi- 
viduals, but  Allan  has  not  been  able  to  find  those  people  who 
constantly  harbor  any  kind  of  amebse  without  symptoms  of 
intestinal  disturbance. 

Diphtheritic  dysentery  constitutes  a  type,  and  also  the 
secondary  diphtheritic  dysentery,  which  may  be  a  terminal 
event  in  acute  or  chronic  disease,  and  in  which  Vedder 
has  demonstrated  the  presence  of  the  bacillus  dysenteric. 

Diagnosis  of  Bacillary  Dysentery. — The  incubation 
period  of  this  type  is  short — not  over  forty-eight  hours,  and 
the  onset  is  usually  sudden,  characterized  by  fever,  pain  in 
the  abdomen,  and  frequent  stools,  first  containing  mucus, 
and  later  consisting  chiefly  of  glairy  mucus  and  blood.  The 
tongue  is  coated,  tenesmus  is  acute,  there  may  be  excessive 
thirst,  nausea  and  vomiting.  The  abdomen  is  not  usually 
distended,  but  there  are  tenderness  over  the  colon  and 
cramp-like  pains  radiating  over  the  whole  abdominal  region. 
The  pulse  increases  in  rate  and  may  become  feeble  and 


528  DIARRHEA   AND   DYSENTERY 

thready.  Urine  is  lessened  and  may  contain  albumen. 
The  temperature  generally  rises,  and  the  patient  presents 
every  appearance  of  being  both  painfully  and  seriously  ill. 

Among  other  clinical  manifestations  of  bacillary  dysen- 
tery are  the  acute  catarrhal  form  and  the  follicular  form,  the 
latter  sometimes  resulting  in  but  little  pseudomembrane 
and  no  deep  sloughing.  The  diphtheritic  type  may  be 
included  among  the  forms  caused  by  the  bacillus  diptheriae 
combined  with  streptococci  and  others.  In  this  there  may 
be  considerable  necrosis  and  infiltration  of  the  mucosa,  and 
at  times  indications  of  general  infection. 

Complications. — These  may  be  many  and  varied,  con- 
sisting of  acute  bronchitis,  pneumonia,  gangrene  of  the 
lung,  albuminuria,  rheumatic  pains  and  swollen  joints, 
pericarditis,  proctitis  and  periproctitis,  and  occasionally 
pyemic  manifestations.  There  is  also  a  frequent  impair- 
ment of  the  digestion  following  bacillary  dysentery,  which 
may  persist  a  long  time. 

Prognosis. — This  varies  with  the  epidemic,  in  some  the 
mortality  being  high.  As  a  rule,  however,  uncomplicated 
cases  in  persons  of  good  physique,  and  where  proper 
attention  can  be  had,  tend  to  recovery,  though  convales- 
cence may  be  tedious. 

Treatment.— Absolute  rest  is  first  in  importance,  and 
should  be  enforced  no  matter  how  mild  the  case  seems  to  be. 
This  is  necessary,  not  only  to  conserve  the  caloric  needs  of 
the  body,  but  it  diminishes  the  activity  of  the  bowels,  as 
peristalsis  is  increased  when  the  intestines  are  pressed  on  by 
the  surrounding  organs,  on  account  of  the  contraction  of  the 
abdominal  muscles  during  the  upright  position  and  walk- 
ing. Many  patients  can  control  the  desire  to  evacuate  the 
bowels  while  quiet  and  recumbent,  but  are  unable  to  check 
the  straining  when  the  body  is  erect  or  in  motion. 

As  suggested  by  Dr.  Meara  in  an  excellent  article,  a 
patient  with  dysentery  demands  as  active  and  careful 
management  by  the  nurse  as  one  with  typhoid  fever. 
Therefore  it  is  preferable  that  the  bed  which  the  patient 


TREATMENT    OF    DYSENTERY  529 

occupies  should  be  narrow  and  high,  and  that  the  springs 
should  be  stiff.  The  mattress  should  not  be  too  hard,  and 
if  it  is  not  smooth,  should  be  covered  by  a  folded  blanket. 
Over  this  is  placed  the  lower  sheet,  which  is  well  tucked 
under  the  mattress,  and  over  this  should  be  spread  a  rubber 
sheet  wide  enough  to  extend  from  the  pillow  to  the  patient's 
knees  and  long  enough  to  be  tucked  under  the  mattress  at 
either  side.  Over  this  should  be  placed  a  draw  sheet, 
which  is  folded  lengthwise  and  placed  across  the  bed  so  as 
to  cover  the  rubber  sheet.  This  may  be  readily  changed 
for  a  clean  sheet  as  often  as  necessary.  The  patient  lies 
on  this  sheet,  and  over  him  should  be  placed  another  sheet, 
and  blankets  in  sufficiency. 

The  room  occupied  by  the  patient  should  be  large,  well 
aired,  and  should  receive  some  sunlight,  although  if  it  is 
summer  time  and  hot  weather,  the  patient  may  not  desire 
too  much  of  this  form  of  light.  A  daily  warm  sponge  bath 
should  be  administered,  with  the  water  at  about  iio°  F. 
One  part  of  the  body  should  be  bathed  after  another,  so  as 
not  to  entirely  uncover  the  body  at  once,  and  so  no  unneces- 
sary fatigue  may  be  caused.  Following  the  bath,  a  gentle 
alcohol  rub  should  be  given,  and  the  back  should  be  dusted 
with  a  bland  powder.  The  last  precaution  is  important, 
especially  in  thin  or  debilitated  individuals,  for  careless- 
ness in  this  particular  may  result  in  chafing,  excoriation  of 
the  back  and  buttocks,  and  even  bedsores.  The  mouth 
should  be  cleansed  frequently,  Dobell's  solution,  or  liquor 
alkaline  antiseptic  (N.  F.)  being  suitable.  If  painful  sto- 
matitis is  in  evidence,  diluted  peroxide  of  hydrogen  solution 
or  chlorate  of  potash  may  be  used,  or  the  buccal  surfaces 
may  be  swabbed  with  a  nitrate  of  silver  solution,  twenty 
grains  to  the  ounce.  For  the  dryness  of  the  mouth,  which 
is  sometimes  so  annoying,  equal  parts  of  a  pure  mineral 
oil  and  a  two  per  cent,  boric  acid  solution,  with  a  little 
lemon  juice,  will  be  found  grateful. 

Unless  the  attack  is  extremely  mild,  the  patient  should 
not  be  allowed  to  leave  the  bed  when  the  bowels  move, 
34 


530  DIARRHEA   AND    DYSENTERY 

but  a  bedpan  should  be  employed.  Some  are  extremely 
averse  to  this  procedure,  declaring  that  they  never  could 
and  never  can  use  a  bedpan,  but  sufficient  persuasion  will 
generally  accomplish  this  important  part  of  the  treatment. 
It  should  be  warmed  before  being  placed  under  the  patient ; 
a  towel  should  be  placed  between  it  and  the  draw-sheet, 
and  he  should  be  assisted  in  raising  his  body  by  the  hand  of 
the  nurse  placed  under  his  back.  After  the  bedpan  has 
been  used,  the  patient  should  be  locally  bathed,  dried, 
gently  rubbed  with  alcohol,  and  powdered. 

In  cool  weather  chilling  of  the  body  should  be  carefully 
avoided ,  and  it  is  sometimes  well  to  place  an  extra  piece  of 
flannel  over  the  abdomen,  while  the  feet  should  be  kept 
warm  by  a  hot-water  bag  placed  between  the  sheets  at  the 
foot  of  the  bed. 

The  diet  is  quite  important,  and  during  the  early  days  of 
the  dysentery  should  be  rather  limited.  In  robust  indi- 
viduals I  frequently  allow  no  food  whatever  for  the  first 
forty-eight  hours,  seeing  to  it,  however,  that  a  sufficiency  of 
water  is  ingested.  Meara  and  others  believe  there  is  noth- 
ing better  for  patients  with  this  trouble  than  milk,  for  it  is 
bland,  non-irritating,  and  non-stimulating  to  the  intestinal 
tract,  is  readily  assimilable,  and  leaves  but  little  residue. 
Occasional  idiosyncrasies  against  milk,  when  really  present, 
should  be  respected.  A  glassful  should  be  given  every  two 
hours,  if  the  stomach  will  hold  it  comfortably,  and  some 
digest  it  better  if  boiled.  Others  prefer  the  raw  milk,  ice- 
cold,  especially  if  the  temperature  is  high.  If  thought 
advisable  by  the  physician,  the  milk  may  be  diluted  at 
pleasure  with  plain  boiled  water,  lime  water,  rice  or  barley 
water.  If,  on  account  of  distress  or  flatulence,  the  milk 
seems  to  be  not  well  borne,  the  possibility  that  the  fat  is  not 
well  digested  should  be  considered,  and  the  milk  may  be 
skimmed  before  it  is  drunk.  After  the  fever  has  subsided 
and  the  stools  become  more  normal,  the  patient  may  take 
barley  jelly  or  well-boiled  rice ;  later  toast  and  soft  egg,  a 
broiled  chop,  and  finally  the  usual  diet,  being  particular  for 


TREATMENT    OF    DYSENTERY  53 1 

a  while  as  to  the  ingestion  of  foods  containing  much  cellu- 
lose. Water  may  be  allowed  frequently,  but  in  small 
amounts  and  not  too  cold,  for  either  very  hot  or  very  warm 
drinks  or  food  tend  to  increase  intestinal  peristalsis.  Should 
milk  continue  to  disagree,  egg-albumin,  or  thin  chicken 
broth  may  be  allowed,  and  to  the  latter  milk  sugar  may  be 
added,  unless  it  increases  flatulence. 

It  is  the  almost  universal  rule  to  commence  the  treatment 
of  dysentery  by  the  administration  of  a  cathartic,  and  the 
three  most  in  use  are  castor  oil,  calomel,  and  the  salines. 
By  this  means  the  intestines  are  emptied  of  the  accumula- 
tion of  sticky  mucus,  and  later,  astringents  will  not  produce 
griping.  When  the  bowels  are  suddenly  checked  before 
first  clearing  out  this  mucus,  the  patient  is  liable  to  suffer 
great  pain  and  increased  fever.  I  do  not  advocate  the  use  of 
calomel,  but  prefer  one  ample  dose  of  either  castor  oil  or  a 
dependable  saline  cathartic.  After  two  or  three  free  move- 
ments, an  astringent  may  be  given,  and  one  containing  a 
small  amount  of  opium  is  preferable,  not  enough,  however, 
to  produce  a  narcotic  effect.  Should  the  griping  continue, 
the  following  prescription  from  Delafield  is  useful : 

I^.     Olei  ricini 3iiss. 

Phenylis  salicylatis gr.  xxv. 

Tr.  opii  deodorati. TTlxv. 

M.  et  ft.  capsulse  15. 

SiG. — -One  capsule  every  two  hours. 

This  prescription  may  be  kept  up  until  the  stools  dimin- 
ish in  frequency,  and  then  permit  the  intervals  to  be 
increased.  Should  this  not  be  efficient,  the  following  is 
useful ; 

I^.     Tr.  opii 5ss. 

Tr.  opii  camphoratag 5iv. 

Spts.  fceniculi 5ii- 

Mist,  rhei  et  sodii q.s.  ad.  gii. 

SiG. — One  teaspoonful  every  two  or  three  hours. 

It  may  be  advisable  to  give  an  extra  dose  of  oil  every 
few  days,  should  the  mucus  and  blood  continue  in  the  stools. 


532  DIARRHEA  AND  DYSENTERY 

For  the  excessive  griping  hot  stupes  and  hot  poultices  are 
indicated.  Turpentine  may  be  added  to  the  stupes,  but 
care  must  be  exercised  lest  the  abdomen  be  blistered. 

Warm  rectal  irrigations  are  recommended  by  some,  but 
it  has  been  my  experience  that  they  increased  both  peristal- 
sis and  discomfort. 

For  the  painful  tenesmus  nothing  is  as  efficaceous  as  the 
local  application  of  opium  and  belladonna  in  suppository: 

I^.     Opii  pulveris gr-  i. 

Ext.  belladonnas  fol gr.   ss. 

Olei  theobromatis 5ss. 

M.  at  ft.  suppositoria  No.  lo. 

SiG. — One  inserted  in  rectum  every  three  to  six  hours. 

If  this  method  is  not  satisfactory,  the  tincture  of  opium 
may  be  added  to  thick  starch- water,  and  about  2  ounces  of 
starch-water  with  fifteen  drops  of  the  tincture  may  be 
gently  injected  into  the  rectum  every  three  to  six  hours  as 
needed. 

Occasionally  a  hypodermic  of  morphin  is  required  for 
excessive  pain,  but  this  should  be  avoided,  if  possible,  as 
the  secondary  nausea  is  usually  distressing,  while  it  checks 
some  of  the  useful  secretions. 

Among  the  astringents  tannigen  is  my  favorite,  and 
with  this  may  be  given  bismuth  subgallate  in  large  doses. 
When  bismuth  is  long  given,  the  precautions  previously 
mentioned  should  be  observed. 

Opium,  while  being  the  most  useful  astringent,  should  be 
continued  with  care,  and,  if  possible,  the  patient  should  be 
ignorant  of  its  use,  otherwise  the  habit  may  become  fixed. 
I  have  seen  a  number  of  confirmed  opium  habitues  who 
informed  me  that  their  bondage  dated  back  to  an  attack  of 
dysentery. 

While  most  patients  recover  from  dysentery  in  five  to 
ten  days,  a  certain  number  continue  for  several  weeks,  and 
then  very  slowly  recover,  or  the  disease  becomes  chronic. 
In  the  chronic  condition  irrigation  is  of  more  use  than  in  the 


TREATMENT    OF    DYSENTERY  533 

acute,  but  care  must  be  taken  that  the  irrigation  does  not 
keep  up  the  trouble. 

An  irrigation  of  plain  warm  water  may  first  be  used, 
followed  by  a  weak  nitrate  of  silver  .solution.  If  the  latter 
causes  much  pain,  it  should  be  followed  by  a  neutralizing 
solution  of  chlorid  of  sodium. 

I  have  during  the  last  two  years  used  high  injections  of 
kerosene  oil  for  intractable  forms  of  bacillary  dysentery, 
especially  in  pellagra,  where  the  early  compensatory  diar- 
rhea had  merged  into  a  painful  dysenteric  state,  and  with 
satisfactory  results.  I  would  recommend  its  trial  in  such 
cases. 

In  these  protracted  cases  there  will  generally  be  found 
ulcers  in  the  rectum,  and  the  symptoms  will  not  yield  until 
these  ulcers  are  properly  treated. 

Patients  with  long-continued  dysentery  often  improve 
greatly  with  change  of  air  and  environment,  and  I  have 
observed  several  instances  in  which,  after  medicine  and 
other  measures  had  failed,  quick  improvement  took  place 
during  a  sojourn  in  the  mountains  or  at  the  seashore.  Many 
of  these  patients,  too,  become  sitophobic  or  fearful  of  food, 
and  consequently  become  thin  and  anemic.  It  is  just  as 
necessary  in  the  promotion  of  healing  in  the  rectum  and 
colon  that  an  adequate  diet  be  ingested  as  in  the  recuper- 
ation from  any  other  exhausting  illness. 

As  this  disease,  like  typhoid  fever,  is  water-borne,  the 
same  precautions  in  regard  to  the  care  of  stools  and  of 
bedding  soiled  by  the  fecal  discharges  should  be  exercised 
as  is  advised  in  tyhpoid  fever;  otherwise  new  cases  may 
soon  develop  in  the  same  house  or  vicinity. 

AMEBIC  DYSENTERY 

Diagnosis. — The  ordinary  mental  picture  of  dysentery 
with  its  outspoken  tenesmus,  small  and  frequent  evacua- 
tions, containing  blood  and  mucus,  and  running  a  rather 
acute  course,  must  be  changed  somewhat  in  regard  to  ame- 


534  DIARRHEA  AND  DYSENTERY 

bic  dysentery,  for  its  variable  and  capricious  syndrome  of 
symptoms  makes  a  purely  bedside  diagnosis  uncertain,  and 
may  even  tend  to  disarm  an  ordinary  suspicion  of  its  exist- 
ence. The  clinical  picture  of  bacillary  dysentery  could 
hardly  be  used  as  a  descriptive  one  for  the  so-called  dysen- 
tery of  amebic  origin.  In  the  first  place  this  condition  is 
practically  always  chronic,  in  the  sense  of  a  protracted 
infection,  and  the  acute  types  occasionally  met  may  be 
looked  on  as  mere  exacerbations.  The  number  of  years  the 
infection  might  exist  in  latent  form,  or,  if  established, 
remain  unrecognized,  is  quite  variable,  and  depends  largely 
upon  the  ability  of  the  physician  making  the  diagnosis. 
S.  K.  Simon,  in  reporting  fifty  cases,  found  one  in  which  the 
disease  could  be  traced  back  twelve  years,  another  eight 
years,  two  for  six  years,  and  in  five  cases  the  condition  had 
been  present  two  years  at  the  time  of  consultation.  The 
average  duration  of  the  cases  was  about  nine  months. 

During  the  course  of  this  disease  there  are  quiescent 
periods,  when  apparently  all  trace  of  the  trouble  has  van- 
ished. The  bowels  might  even  become  markedly  consti- 
pated. The  amebse  remain,  however,  constantly  under 
cover  during  this  time,  the  infection  suddenly  flaring  out 
again  under  favorable  conditions  for  renewed  activity. 
The  occasional  attacks  of  diarrhea,  alternating  with  periods 
of  normal  evacuation  or  constipation,  make  up  a  suggestive 
picture  of  amebiasis,  and  when  present  should  lead  to  an 
immediate  examination  of  the  stools  for  amebae. 

When  attacks  of  diarrhea  do  occur,  the  number  and 
character  of  the  evacuations  do  not  follow  any  set  rule,  for 
a  great  deal  depends  on  the  location  of  the  ulcers.  If  low 
down,  and  especially  if  in  the  rectum,  the  evacuations  are 
usually  frequent,  accompanied  by  a  marked  tenesmus  and 
soreness  of  the  lower  bowel.  If  the  main  lesions  are  above 
the  sigmoid,  as  they  often  are,  the  number  of  stools  may 
never  average  more  than  two  or  three  a  day.  Mucus 
may  or  may  not  be  present,  but  commonly  is.  Pure  blood, 
or  a  blood-streaked  mucus,  I  have  found  to  be  fairly  con- 


TYPES    OF    AMEBIC    DYSENTERY  535 

stant,  though  at  times  in  only  small  amounts.  In  fatal 
cases  with  liver  abscess,  according  to  Strong,  hemorrhages 
are  frequent. 

In  regard  to  age,  this  is  a  disease  of  adult  and  middle 
life,  being  rare  among  children  and  aged  people.  The  col- 
ored race  do  not  suffer  much  from  amebiasis,  though  they 
are  not  entirely  exempt,  and  among  all  races  the  males  seem 
to  be  mostly  affected.  Occupation  and  greater  exposure 
of  males  to  infection  in  general  is  the  probable  explanation 
of  the  last  assertion. 

Musgrave  has  classified  the  main  types  as  follows: 
(i)  Latent  and  masked  infection  with  the  amebae. 

(2)  Mild  and  moderately  severe  infections  (subacute 
dysentery) . 

(3)  Severe  infection,  including  gangrenous  and  diphther- 
itic types  (acute  dysentery). 

(4)  Chronic  dysentery. 

In  the  latent  infection  there  may  be  a  pathologic  amebic 
process  in  the  intestines,  without  any  diarrhea  or  other 
symptoms  that  would  indicate  the  infection.  Dull,  aching 
abdominal  pains  are  present,  which  are  attributed  to  catch- 
ing cold.  They  first  appear  and  are  most  active  during  the 
night  or  early  morning,  and  are  accompanied  by  indiges- 
tion, headache,  lassitude,  coated  tongue,  loss  of  appetite 
and  weight,  and  at  times  a  yellow  skin. 

Physical  examination  discloses  on  deep  palpation  tender- 
ness along  the  colon,  especially  over  the  cecum  and  ascend- 
ing colon.  This  last  is  quite  a  significant  symptom.  If  a 
hydragogue  cathartic  is  administered,  there  can  generally 
be  found  in  the  stools  amebae,  mucus,  tissue  elements,  and 
often  old  blood. 

In  the  moderately  severe  manifestations  of  amebiasis, 
the  aspect  of  diarrhea  may  be  more  prominent  than  that  of 
dysentery,  and  the  trouble  may  develop  from  the  latent 
type.  There  are  noted  abdominal  pain,  tenderness  along 
the  colon,  headache,  digestive  disturbances,  irritability  and 
loss  of  weight.     Amebae  are  found  in  the  diarrheal  move- 


536  DIARRHEA  AND  DYSENTERY 

ments,  and  some  of  these  patients  never  show  any  dysen- 
teric stools,  even  without  treatment. 

In  these  somewhat  atypic  cases  of  loose  bowels  with 
contained  ameb^  may  be  mentioned  the  interesting  report 
of  Dr.  William  Allan,  who  has  found  in  the  stools  of  pella- 
grins both  the  entameba  coli  and  the  entameba  histolytica. 
He  claims  that  there  is  danger  of  mistaking  amebiasis  for 
pellagra  and  vice  versa.  In  this  I  hardly  agree,  for  a  care- 
ful study  of  either  disease,  each  of  which  is  a  pathologic 
entity,  shoudl  serve  to  stamp  the  diagnosis. 

Cases  of  amebic  dysentery  slightly  more  severe  will 
show  a  diarrhea  marked  in  the  morning,  consisting  of 
several  semi-fluid  stools,  with  neither  mucus  nor  blood, 
but  increasing  in  intensity  until  both  appear. 

Finally,  in  the  severe  cases,  the  onset  is  sudden,  with 
marked  abdominal  colic,  diarrhea  with  tenesmus,  and  great 
straining.  Later  there  may  be  passed  sloughs  consisting  of 
gray  or  blackish  masses  of  necrotic  tissue  of  very  foul  order. 
The  temperature  may  not  be  high,  but  the  patient  rapidly 
emaciates.  Death  may  occur  in  a  week  after  the  onset. 
Intestinal  hemorrhage  or  general  peritonitis  may  take  place, 
or  extensive  ulceration  may  remain  after  the  sloughing, 
causing  a  chronic  diarrhea  which  exhausts  the  patient.  In 
such  cases  as  many  as  twenty  or  thirty  stools  may  be  passed 
in  the  day,  all  of  them  containing  blood  and  mucus,  per- 
haps gangrenous  fragments  of  tissue.  Anorexia,  nausea 
and  vomiting  may  occur,  and  with  the  great  prostration 
may  come  cold  extremities,  delirium,  stupor,  and  cerebral 
disorders. 

Should  death  be  averted,  the  disease  may  pass  into  the 
chronic  state  with  ulcerated  intestines  and  all  the  long- 
continued  symptoms  that  go  with  these  intestinal  lesions. 

While  the  disease  does  not  often  affect  the  extremes  of 
life,  Musgrave  has  reported  from  the  Philippines  cases  in 
infants  of  six  months,  and  in  persons  over  sixty  years 
of  age. 

The  only  way  in  which  a  positive  diagnosis  of  amebiasis 


PROGNOSIS    OF   AMEBIC   DYSENTERY  537 

can  be  made  is  by  the  microscope,  and  by  the  finding  of  the 
protozoa  in  the  stools.  In  regions  where  the  disease  is 
endemic  and  a  microscope  is  not  available,  one  can  reason- 
ably infer  its  presence  by  the  most  valuable  symptom, 
namely,  abdominal  soreness,  which  is  increased  on  pressure, 
and  extends  along  the  course  of  the  colon,  especially  when 
there  is  maximum  intensity  over  the  cecum  and  ascending 
colon.  I  believe  with  Musgrave  that  the  presence  in  the 
stools  of  any  form  of  ameba  in  warm  or  tropical  regions 
should  be  considered  diagnostic  for  purposes  of  treatment, 
whether  or  not  active  symptoms  are  present. 

Prognosis. — This  is  largely  determined  by  the  period  of 
its  recognition  and  the  type  of  the  disease.  In  a  general 
way  it  may  be  said  that  the  longer  the  infection  has  con- 
tinued the  greater  probability  there  is  of  serious  complica- 
tions. In  Simon's  fifty  cases,  28  per  cent,  died,  and  in 
fifteen  out  of  the  seventeen  fatal  cases  the  cause  of  death  was 
determined  accurately  by  post-mortem.  Extensive  ulcera- 
tions of  the  large  bowel  were  found  in  practically  all,  and 
in  nine  instances  seemed  the  sole  cause  of  the  fatal  termi- 
nation. Perforation  was  observed  in  but  one  case,  while 
six  abscesses  of  the  liver  were  discovered,  five  solitary  and 
one  multiple.  In  Futcher's  cases  liver  abscess  was  diag- 
nosed in  23  per  cent.,  and  in  Craig's  33  per  cent.  This 
complication,  it  will  therefore  be  noted,  is  important,  and 
its  possibility  should  always  be  considered.  The  diag- 
nostic puncture  of  the  liver  is  not  a  dangerous  operation, 
and  the  use  of  the  aspirator  is  indicated  when  the  merest 
grounds  for  suspicion  are  present.  Only  thus  may  a  serious 
and  often  irretrievable  oversight  be  avoided. 

Under  proper  treatment  recovery  is  the  rule  in  the  young 
and  well-nourished  adults,  if  the  disease  is  not  of  long  dura- 
tion. The  early  diagnosis  and  treatment  are  the  important 
considerations  in  the  prognosis,  as  otherwise  apparently 
mild  cases  may  assume  a  dangerous  character,  complica- 
tions may  arise,  and  it  may  either  enter  into  a  chronic 
course,  or  death  may  ensue. 


538  DIARRHEA  AND  DYSENTERY 

Treatment  of  Amebic  Dysentery — Musgrave  holds  that 
the  best  rule  to  observe  in  localities  or  countries  where  the 
disease  is  endemic  is  to  take  nothing  into  the  gastrointes- 
tinal tract  which  has  not  been  sterilized.  This  is  not  always 
possible.  The  drinking  water  should  be  boiled,  and  dishes 
and  the  hands  of  attendants  should  be  washed  in  boiled 
water.  Raw  fruits  and  vegetables  should  be  first  placed  on 
ice,  and  then  have  scalding  water  poured  over  them, 
which  kills  the  amebse.  The  stools  should  be  disinfected 
in  carbolic  acid  or  bichlorid  of  mercury  solutions,  and  the 
same  precaution  taken  with  soiled  linen. 

The  acid  of  the  stomach  lessens  the  chances  of  infection, 
and  acid  mixtures  are  helpful  for  this  purpose. 

In  the  acute  form  the  patient  should  be  put  to  bed  and 
placed  on  a  liquid  diet,  with  the  same  dietetic  precautions 
as  in  acute  bacillary  dysentery.  I  have  heard  from  several 
sources  the  advocacy  of  liberal  allowances  of  tender  turnip 
* '  greens ' '  made  into  a  puree  for  this  condition,  and  have  also 
heard  glowing  accounts  of  good  results  following.  I  am 
not  able  to  find  any  logical  reason  for  such  diet,  and  am 
skeptical  as  to  its  curative  results,  though  I  have  neither 
had  nor  sought  any  experience  with  this  somewhat  unique 
method. 

Local  applications  for  the  abdominal  pain,  general  care 
of  the  patient,  and  the  employment  of  other  symptomatic 
measures  are  practically  the  same  as  in  the  treatment  of 
other  forms  of  acute  or  chronic  intestinal  irritation. 

The  crux  of  the  whole  therapeutic  problem  is  to  destroy 
the  ameb«,  and  later  to  heal  the  ulcerated  intestines  and 
cure  other  possible  complications. 

For  the  destruction  of  the  amebse  there  are  two  methods 
of  internal  medication  and  one  of  local  irrigation  which  are 
practically  specific,  and  the  physician  may  be  spared  trying 
the  numerous  remedies  which  he  can  find  recommended  by 
some  who  have  had  but  little  actual  experience  in  the  treat- 
ment of  this  disease — I  refer  to  the  internal  administration 
of  ipecac,  the  hypodermic  administration  of  emetin  hydro- 


TREATMENT    OF    AMEBIC    DYSENTERY  539 

chlorid,  and  the  high  injection  into  the  large  intestine  of 
kerosene  oil. 

For  many  years  ipecac  has  been  held  in  the  highest 
esteem  in  East  India  and  neighboring  Oriental  countries, 
and  while  in  some  quarters  it  is  unfavorably  regarded,  it 
has  the  endorsement  of  Manson,  of  England,  and  Siler  of  this 
country.  I  have  had  the  opportunity  of  using  it  in  a  num- 
ber of  cases,  and  my  results  have  been  satisfactory. 

In  the  administration  of  ipecac  several  details  must  be 
observed,  or  the  stomach  will  not  retain  it  and  the  results 
are  not  good.  First  of  all,  the  drug  should  be  administered 
only  in  pill  form  and  these  pills  should  be  coated  about  an 
eighth  of  an  inch  with  phenyl  salicylate  (salol) ;  for  this 
coating  does  not  readily  dissolve  in  the  stomach,  and  it  is 
necessary  that  the  ipecac  get  beyond  the  stomach  before  it  is 
absorbed,  lest  the  emetic  effect  cause  the  patient  to  reject 
it.  The  pills  should  generally  contain  5  grains  each  of  the 
ipecac. 

If  desired,  castor  oil  may  be  given  ten  or  twelve  hours 
before  the  ipecac  is  to  be  administered,  and  my  usual 
mode  is  as  follows :  No  food  is  allowed  for  six  hours,  and  no 
water  for  three  hours.  The  patient  is  kept  on  his  back  and 
the  pills  swallowed  with  as  little  fluid  as  possible.  Twenty 
drops  of  tincture  of  opium  should  be  given  thirty  minutes 
before  the  ipecac  pills.  After  this  he  should  not  be  allowed 
to  move  or  speak  or  expectorate,  and  the  nurse  should 
keep  a  cold  cloth  over  his  throat  and  should  frequently 
bathe  his  face.  His  head  should  be  kept  low,  and  both 
physical  and  psychic  quiet  enjoined.  He  may  move 
gently  on  his  right  side  in  an  hour,  but  should  not  be  allowed 
any  water  until  three  hours  have  elapsed  after  taking  the 
pills,  and  then  sparingly.  In  this  way  the  pills  are  gener- 
ally retained;  but,  should  they  be  rejected,  the  same  pro- 
cedure may  be  repeated  the  following  day  or  night.  After 
six  or  seven  hours  he  may  take  a  glass  of  milk  or  some  light 
broth,  if  he  desires. 

The  dose  of  ipecac  should  be  about  40  or  50  grains  the 


540  DIARRHEA   AND    DYSENTERY 

first  night  (eight  or  ten  pills),  and  reduced  ten  grains  each 
night  until  only  lo  grains  are  given.  It  is  well  then  to 
continue  this  lo-grain  dose  every  night  for  ten  days  or  two 
weeks. 

Given  this  way  ipecac  appears  almost  as  a  specific,  and 
under  its  influence  the  stools  become  soft  and  mushy,  but 
soon  lose  their  dysenteric  character,  and  may  assume  a 
normal  form  in  a  few  days,  while  the  amebae  disappear 
almost  at  once. 

The  modus  operandi  of  ipecac  was  not  well  understood 
until  in  March,  191 1,  Vedder,  working  in  Manila,  published 
his  findings  that  a  fluid  extract  of  ipecac  would  kill  amebae 
in  cultures  in  dilutions  as  high  as  1:200,000.  The  next 
year  Rogers  in  Calcutta  found  that  emetin  hydrochlorid 
killed  amebae  in  stools  of  in  dilutions  i :  100,000,  and.  began 
the  use  of  this  salt  hypodermically  in  cases  of  amebic 
dysentery.  Since  then  this  preparation  has  been  exten- 
sively employed,  and  present  results  seem  highly  satis- 
factory. 

There  are  variations  in  the  method  of  its  use,  and  there  is 
not  yet  a  unanimity  of  opinion  as  to  the  best,  but  from  one- 
third  to  four-fifths  of  a  grain  may  be  used  hypodermically 
every  day  or  every  alternate  day  until  good  results  appear, 
or  the  amebae  disappear  from  the  stools.  Allan,  of  Char- 
lotte, has  experimented  rather  extensively  with  this  salt, 
and  reports  giving  it  in  doses  of  as  high  as  2  1/4  grains 
without  vomiting.  He  reports  one  case  in  which  4  grains 
were  given  hypodermically,  but  in  this  nausea  occurred. 

It  is  probable  that,  as  the  effects  of  emetin  hydrochlorid  are 
better  understood,  larger  doses  will  be  given  than  are  now 
recommended,  and,  as  Allan  found  that  the  amebae  disap- 
peared much  more  quickly  when  the  large  doses  were  given, 
and  as  he  found  that  2  grains  produced  no  nausea  nor  vomit- 
ing, the  dose  now  usually  recommended  may  be  increased 
with  safety  and  efficiency. 

High  Injection  of  Kerosene  Oil. — This  procedure  is  of 
recent  date,  and  has  not  come  into  general  use,  but  is  a 


TREATMENT    OF    AMEBIC    DYSENTERY  54I 

valuable  aid  in  amebic  dysentery.  For  an  adult  about  a 
pint  of  the  pure  oil  should  be  employed,  and,  with  the 
patient  in  the  knee-chest  position  should  be  injected  high 
up  in  the  bowel  through  a  colon  tube.  He  should  keep  this 
position,  in  an  exaggerated  manner  if  possible,  for  several 
minutes  so  the  oil  will  gravitate  into  the  colon.  This 
injection  should  be  retained  for  thirty  to  forty  minutes, 
and  then  permitted  to  escape,  though  if  all  does  not  escape 
at  once,  no  alarm  need  be  felt.  R.  T.  Dorsey  reports  one 
case  where,  through  a  misunderstanding  of  orders,  the  oil 
was  allowed  to  remain  in  the  bowel  over  two  hours.  No  ill 
effects  occurred. 

This  injection  may  be  repeated  daily  for  three  or  four 
days,  and  then  occasionally,  as  required.  It  will  be  found, 
however,  that  not  many  will  be  needed,  for,  unless  the  case 
is  extremely  far  advanced,  improvement  will  promptly 
set  in. 

Deeks,  at  the  Ancon  Hospital,  employs  chiefly  the  sub- 
nitrate  of  bismuth  treatment,  giving  1 1/2  drams  by  measure- 
ment or  about  3  drams  by  weight,  stirred  in  a  glass  of 
water,  every  three  hours.  Normal  saline  or  plain  water 
irrigation  of  the  bowels  are  added.  Rest  in  bed  and  an 
absolute  milk  diet  are  enforced,  and  an  occasional  dose  of 
morphin  and  atropin  are  allowed  for  the  pain.  Deeks 
claims  good  results  from  this  method,  but  recommends 
appendicostomy,  or  cecostomy,  if  the  symptoms  persist. 

It  would  appear  to  the  writer  that  surgery,  expecially 
that  entailing  the  formation  of  an  artificial  anus,  should 
hardly  be  recommended  in  this  disease,  except  in  extremely 
intractable  cases. 

Other  solutions  for  local  treatment,  which  have  been 
advised  are: 

Acetozone,  i  :iooo  and  alphozone  in  the  same  strength. 
These  are  claimed  to  destroy  amebas  and  other  bacteria. 

Protargol,  argyrol,  bisulphate  of  quinin,  each  1:500; 
silver  nitrate,  1:2000;  thymol,  1:2500,  or  permanganate 
of  potash,   1:2500 — all  these  are  probably  of  some  value 


542  DIARRHEA   AND   DYSENTERY 

both  for  their  germicide  properties  and  as  astringents. 
Hydrogen  peroxid  has  been  used  by  some  with  satisfaction, 
and  Tuttle  has  recommended  cold  water  at  a  temperature 
under  45°  F.  as  destructive  to  amebae. 

Other  medication,  diet,  physical  measures,  etc.,  are 
similar  to  those  indicated  for  other  conditions  resulting  in 
similar  lesions  of  the  intestines;  for  the  general  symptoms 
need  to  be  appropriately  treated  as  they  arise,  while  strenuous 
efforts  should  be  put  forth  to  conserve  and  improve  the 
patient's  bodily  strength.  A  change  from  a  warm  to  a 
cool  climate  is  nearly  always  of  benefit,  and  on  several 
occasions  I  have  known  of  marked  improvement  quickly 
following  such  a  change. 

Regarding  abscess  of  the  liver,  Rogers  states  that  in  the 
presuppurative  stage  there  is  exacerbation  of  temperature, 
usually  increased  pain  in  the  liver  region,  and  leucocytosis. 
With  suppuration  there  is  increased  density  of  the  liver 
shadow  to  the  X-rays,  local  swelling,  and  edema  with  in- 
creasing leucocytosis.  Rogers  claims,  however,  that  86  per 
cent,  of  these  abscesses  are  sterile  and  are  infected  by 
other  bacteria  by  the  open  operation.  He  recommends 
repeated  aspirations  of  the  abscess  cavity  with  the 
injection  of  quinin  solution,  and  no  drainage.  This  method 
failing,    he   adds    sterile    siphon    drainage. 

Amebic  dysentery,  like  duodenal  ulcer,  is  probably  much 
more  prevalent  than  has  been  supposed,  and  its  frequency 
has  been  shown  by  more  thorough  diagnostic  methods. 
By  carefully  examining  every  suspected  case  of  possible 
amebic  infection,  and  by  early  and  energetic  treatment, 
this  otherwise  serious  disease  can  in  nearly  every  instance 
be  promptly  and  permanently  relieved. 


CHAPTER  XXII 
CONSTIPATION 

Constipation,  like  diarrhea  is  a  comparative  term,  and 
may  be  defined  as  a  condition  in  which  the  feces  are  not 
passed  sufficiently  often  or  in  sufficient  quantity.  The 
quantity  of  feces  is  somewhat  variable,  from  loo  to  i6o 
grams  being  the  daily  average,  though  in  vegetarians  this 
may  be  greatly  increased.  Much  of  the  bulk  of  the  fecal 
evacuations  is  composed  of  bacteria,  of  which  Herter  has 
estimated  the  daily  number  as  126,000,000,000,  which 
explains  the  fact  that  patients  who  eat  but  little  may  pass 
considerable  fecal  matter. 

There  are  many  and  various  grades  of  constipation,  and 
what  might  be  considered  constipation  in  some  individuals 
would  not  be  considered  so  in  others,  as  it  depends  to  a 
great  extent  on  the  habit  of  the  bowels. 

Constipation  may  be  acute  or  chronic,  and  the  former 
may  be  due  to  complete  obstruction  of  the  intestinal  tract 
or  to  post-operative  ileus  and  intestinal  paresis.  An 
almost  complete  obstruction  may  sometimes  also  result 
from  kinks  and  angulations  in  the  intestines  brought  about 
by  enteroptosis,  or  from  constricting  bands  which  diminish 
the  lumen  of  the  canal. 

Strictly  speaking,  constipation  is  not  a  disease,  but  the 
symptom  of  various  pathologic  states.  The  latter  may  con- 
sist of  gross  anatomical  changes  in  the  rectum  or  other  parts 
of  the  gastrointestinal  tract,  or  merely  of  nervous  inhibition 
due  to  stimulation  of  the  splanchnic  from  central  emotion ; 
yet  there  is  always  a  cause  even  in  those  cases  which  are 
produced  by  irregular  habits  in  not  answering  the  call  of 
Nature,  and  a  proctitis  and  dilatation  of  the  rectum  may 
be  a  feature.     It  is  of  the  utmost  importance  to  look  upon 

543 


544 


CONSTIPATION 


constipation  as  a  symptom,  for  the  whole  treatment  depends 
upon  this  viewpoint. 

The  causes  may  be  divided  into  mechanical,  inflam- 
matory, reflex  and  neuromuscular.  The  first  two  are  by 
far  the  most  frequent,  and  before  ascribing  constipation  to  a 
nervous  cause,  as  neurasthenia  or  hysteria,  it  is  much  wiser 
to  search  for  an  anatomical  reason,  such  as  obstructions  or 
inflammation. 

Obstructions  at  any  point  of  the  gastrointestinal  tract 
from  the  esophagus  to  the  anus,  and  from  any  cause  what- 
ever, are  capable  of  giving  rise  to  the  symptom  of  constipa- 


FiG.  8 1. — V-shaped  ptosis  of  transverse  colon. 

tion.  Thus,  cancers  of  the  esophagus  or  pylorus  nearly 
always  produce  small  and  infrequent  movements,  and  one  of 
the  common  symptoms  of  gastric  dilatation  with  obstruc- 
tion due  to  ulcer  or  any  other  condition  is  obstinate  consti- 
pation. In  such  cases  huge  doses  of  cathartic  medicine 
set  up  no  action  of  the  bowels  whatever  before  gastroen- 
terostomy, because  these  agents  cannot  reach  the  intestines. 
Tumors  or  stenosis  of  any  part  of  the  intestines,  when 
developed  enough  to  obstruct  the  lumen  will  cause  scant 
stools,  not  necessarily  hard,  but  small  in  quantity.  This 
applies  to  cancer  or  benign  tumors  of  the  hepatic  and  splenic 
flexures  of  the  colon  as  well  as  those  of  the  rectum. 


CAUSES    OF    CONSTIPATION 


545 


The  influence  of  adhesions  and  angulations  of  the  intes- 
tines as  a  factor  in  constipation  is  becoming  well  recog- 
nized. Kemp  goes  on  record  with  the  statement  that  from 
15  to  20  per  cent,  of  all  women  have  enteroptosis,  and  fully 
30  per  cent,  of  women  coming  to  him  for  treatment  of  the 
gastrointestinal  tract  are  sufferers  from  this  condition. 

It  is  extremely  porbable  that  adhesions  affecting  the  intes- 
tines of  slight  or  moderate  degree,  not  sufficient  to  cause 
stenosis,  are  responsible  for  a  disturbance  of  both  their 
motor  and  secretory  functions.  In  effect,  therefore,  as  as- 
serted by  Kemp,  careful  investigation  will  demonstrate,  in 


Fig.  82. — V-shaped  duodenum  lying  to  right  of  spine. 

quite  a  large  proportion  of  cases  of  so-called  atonic  con- 
stipation, that  enteroptosis  with  moderate  angulations  or 
that  slight  adhesions  are  factors.  This  he  and  others 
have  demonstrated  by  radiographs.  Kemp  also  believes 
that  adhesions  with  narrowing  of  the  intestinal  canal,  as 
well  as  enteroptosis  with  marked  angulations,  are  frequent 
factors  in  the  production  of  so-called  spastic  constipation,  as 
he  has  seen  the  typic  symptoms  with  the  evacuation  of 
small  balls,  or  pencil-shaped  stools,  occur  in  the  above- 
stated  conditions. 

Tuttle  mentions  finding  bands  of  adhesions  which  arose 
from  a  chronic  appendix  or  from  pelvic  peritonitis  due  to 

35 


546 


CONSTIPATION 


pus  tubes  which  tied  down  the  sigmoid  portion  of  the  colon, 
and  caused  most  intractable  constipation  by  preventing 
the  normal  straightening  out  of  the  sigmoid  when  filled 
with  feces  prior  to  its  emptying  into  the  rectum,  thus  leaving 
a  kink  and  difficult  uphill  passage  of  stool.  Such  cases  he 
has  repeatedly  cured  by  cutting  the  adhesions,  removing  the 
appendix  or  other  offending  organs,  and  .stitching  the  sig- 
moid to  the  abdominal  wall. 

Among  the  inflammatory  causes  of  constipation  we  have 
chiefly  to  consider  the  chronic  catarrhal  inflammations  of  the 
intestine,  particularly  of  the  colon,  sigmoid  and  rectum. 


Fig.  83. — Cecal  ptosis. 

These  are  quite  common,  and  even  if  not  the  primary 
faults,  they  at  least  promote  its  continuance.  It  has  been 
noted  that  once  low-grade  catarrhal  inflammation  begins, 
then  constipation  occurs,  while  the  constipation  itself 
increases  the  inflammation,  and  so  on. 

The  reflex  causes  of  constipation  most  frequently  ema- 
nate from  the  stomach  in  hyperacidity,  appendix,  female 
generative  organs,  gall-stones,  hemorrhoids,  anal  fissures, 
etc. 

Among  the  neuromuscular  factors  we  have  lead-poison- 
ing, which  sets  up  a  spasmodic  contraction  of  the  intestines 
without  the  rhythmic  relaxation  necessary  to  normal  peris- 


CAUSES    OF    CONSTIPATION 


547 


talsis;  and  in  another  group  is  found  asthenic  states,  as 
chlorosis,  anemia  and  general  weakness  from  any  cause, 
which  may  decrease  the  peristaltic  force  of  the  neuro- 
muscular mechanism. 

Other  important  causes  are  ingestion  of  insufficient 
water  with  meals  or  between;  an  habitual  diet  containing 
but  little  residue,  whereby  the  intestines  lack  their  normal 
stimulus  to  contraction;  a  sedentary  life  which  promotes 
intestinal  stasis;  irregular  habits  and  failure  to  heed  the 
inclination  to  empty  the  bowels  when  the  "call"  is  felt, 
whereby  the  valuable  influence  of  the  subconscious  stimuli 


Fig.  84. — Cecal  ptosis  displacing  hepatic  flexure. 

to  intestinal  peristalsis  is  lost — all  these  exert  their  malign 
power  in  the  inauguration  and  perpetuation  of  the  consti- 
pated habit. 

Clinically,  constipation  may  be  divided  into  (i)  atonic, 
(2)  spastic,  and  (3)  obstructive. 

Diagnosis. — Acute  constipation  should  be  diagnosed 
when  evacuations  of  the  bowels  cannot  be  obtained  by 
ordinary  measures,  and  when  the  accumulation  of  fecal 
contents  produces  active  symptoms.  This  condition  may 
mean  absolute  obstruction,  and  may  require  prompt  and 
energetic  measures  to  avoid  a  fatal  issue. 

Chronic  constipation  generally  begins  in  the  atonic  form, 


548  CONSTIPATION 

and  manifests  itself  by  a  simple  inability  to  evacuate  the 
bowels.  It  may  be  confidently  diagnosed  in  those  who 
have  long  eaten  a  concentrated  diet  with  perhaps  insuffi- 
cient fluids,  who  have  led  an  inactive  life,  whose  muscular 
system  is  below  par,  or  those  who  have  from  an  unmethod- 
ical life  been  unable  to  empty  the  bowels  regularly,  or  from 
carelessness  and  inattention  have  drifted  into  this  unfor- 
tunate state.  In  this  class  may  generally  be  included  those 
who  have  depended  upon  cathartic  stimulation,  and 
whose  bowels  have  become  absolutely  unresponsive  to  any 
ordinary  natural  or  psychic  influences. 

The  catarrhal  stage  is  but  an  advance  beyond  the  atonic 
condition,  and  its  diagnosis  is  made  possible  by  the  presence 
of.  membranous  mucus  surrounding  the  scybala.  We  do 
not  accurately  know  the  real  condition  of  the  small  intes- 
tine at  this  stage,  but  may  assume  that  a  catarrhal  condi- 
tion has  gradually  developed  here  also. 

The  spastic  stage  sets  in  when  the  secondary  entero- 
colitis, or  the  continued  abuse  of  cathartics  has  irritated 
the  colon,  so  that  a  persistent  hypertonicity  of  its  muscu- 
lature has  developed. 

In  the  atonic  stage  the  patient  complains  of  nothing  more 
severe  than  constipation,  a  dull  feeling,  slight  headache, 
inability  to  think  quickly,  and  perhaps  impaired  appetite. 
Laxatives,  or  effective  enemas  temporarily  afford  relief. 

In  the  objective  examination  the  stools  will  show  normal 
consistency,  and  will  be  covered  by  the  normal  amount  of 
mucus.  The  sigmoid  flexure,  and  usually  the  transverse 
colon  will  be  found  filled  with  feces,  and  will  give  a  doughy 
feel  upon  palpation.  No  special  pain  nor  flatulence  are 
present. 

In  spastic  constipation,  the  following  differential  symp- 
toms will  serve  to  diagnose  it  from  the  atonic : 

(i)  Colic  is  a  frequent  symptom,  in  slight  cases  flatulent 
colic,  in  severe  ones,  mucous  colic.  Nearly  every  case  of 
chronic  constipation  that  runs  its  course  with  attacks  of  pain 
belong  to  the  spastic  type. 


PROGNOSIS  549 

(2)  Laxatives  are  either  not  effective  at  all,  or  only  so 
when  given  in  tremendous  doses,  which  produce  griping  and 
pain.     Enemas  likewise  are  not  effective. 

(3)  Objectively,  on  palpation,  the  transverse  colon  and 
the  sigmoid  flexure  are  found  to  resemble  a  hard  cord,  about 
the  size  of  the  little  finger,  and  is  quite  sensitive. 

(4)  Examination  of  the  rectum  discloses  an  empty  gut, 
or  else  it  is  filled  with  small  and  hardened  feces,  about  the 
size  of  the  little  finger.  In  atonic  constipation  the  rectum 
is  usually  filled. 

(5)  The  stool  is  of  small  caliber,  sometimes  ribbon-shaped, 
or  even  slightly  quadrangular.  It  is  frequently  cut  into  short 
segments.  In  the  atonic  form  the  feces  are  voided  in  large 
solid  lumps,  of  irregular  shapes  and  sizes. 

The  obstructive  form  of  constipation  must  be  diagnosed 
either  from  physical  examination  or  by  means  of  the 
X-ray.  It  may  be  reasonably  supposed  to  be  present  in 
individuals  with  decided  enteroptosis,  especially  when  con- 
stipation is  chronic,  and  the  movements  are  both  difficult 
and  uncomfortable.  I  have  known  several  instances 
in  which  the  act  of  defecation  was  looked  upon  as  almost 
a  torture,  and  was  postponed  as  long  as  possible  through 
fear. 

"Lane's  kinks"  and  "Jackson's  veil"  or  membrane  are 
now  receiving  much  attention  from  the  surgeons,  and 
undoubtedly  exert  a  decided  influence  in  constipation. 

Prognosis. — This  depends  on  the  length  of  the  habit,  the 
underlying  cause,  and  greatly  on  the  intelligence  and 
perseverance  of  the  patient.  After  a  constipation  is  over- 
come, unless  the  original  causes  are  abated,  it  will  in  all 
probability  return.  The  obstructive  form  is  occasionally 
only  amenable  to  surgical  treatment,  and  the  spastic  type 
depends  on  the  healing  of  the  lesions  which  generally  keep 
up  the  spasm.  In  the  functional  cases  of  habitual  consti- 
pation, the  patient  may  be  cured  and  stay  cured  in  the 
majority  of  instances,  if  he  will  strictly  obey  orders  and 
exercise  both  patience  and  perseverance. 


5  so  CONSTIPATION 

Treatment. — General  treatment  consists  in  teaching  the 
patient  the  underlying  causes  of  constipation,  so  that 
intelligent  cooperation  may  be  secured,  and  the  subcon- 
scious powers  employed  to  their  best  advantage.  An  out- 
door life  with  exercise  in  plenty  should  be  encouraged,  and 
regular  habits  as  to  visiting  the  toilet  should  be  specially 
insisted  upon. 

Diet. — The  main  idea  is  the  ingestion  of  foods  which 
contain  a  liberal  proportion  of  residue,  and,  where  there  is 
no  intestinal  inflammation,  even  a  certain  amount  of  irritat- 
ing particles,  so  the  intestinal  mucosa  may  be  stimulated. 
A  glass  of  cold  or  hot  water  should  be  taken  upon  arising,  so 
as  to  inaugurate  early  peristalsis,  and  an  abundance  of  water 
should  be  drunk  at  and  between  meals. 

Among  the  articles  of  food  which  should  be  recommended 
are  buttermilk,  cider,  lactone  buttermilk;  raw  fruits,  such 
as  grapes,  oranges,  grapefruit,  apples  (unpeeled),  figs, 
prunes,  cranberries,  pears,  peaches,  plums,  gooseberries, 
currants,  strawberries,  raspberriers,  blackberries;  cooked 
fruits,  jams,  honey,  lemonade;  vegetables  rich  in  cellulose, 
as  cabbage,  cucumbers,  spinach,  greens,  Brussells  sprouts, 
cauliflower,  green  salads,  Spanish  onions,  carrots,  asparagus; 
syrup,  sugar;  salmon,  sardines,  herring;  rye  bread,  Graham 
bread,  brown  bread,  pumpernickel;  fatty  foods,  plenty  of 
butter,  cream  and  olive  oil.  Oatmeal  and  some  of  the 
cereals  are  of  value;  also  cornbread,  whole  wheat  flour 
bread,  and  bran  biscuits.  Excess  of  potatoes  and  rice  may 
constipate,  and  sweet  milk,  especially  when  boiled,  is 
constipating  to  many.  Whortleberries  are  constipating, 
and  red  wines,  tea,  chocolate  and  cocoa  should  be  pro- 
hibited. Chicken  and  red  meats  may  be  given  in  modera- 
tion, but  it  should  be  remembered  that  the  flesh  proteins  are 
nearly  all  consumed,  leaving  but  little  residue. 

Massage  by  a  trained  attendant,  and  automassage,  as 
described  in  the  chapter  on  mechanical  methods,  are 
often  of  use  in  atonic  constipation,  but  harmful  in  spastic. 
Gymnastic  exercises,  which  bring  into  play  the  abdominal 


TREATMENT    OF    CONSTIPATION  55 1 

muscles  are  of  some  service;  and  the  Swedish  movements 
are  occasionally  of  benefit.  Electricity  may  also  be  used  in 
the  atonic  cases. 

Hydrotherapy  in  the  form  of  baths,  fomentations,  wet 
binders,  and  Priessnitz  compresses  are  all  of  service,  but 
are  not  often  thoroughly  carried  out  except  at  sanatoria. 

Injections  into  the  lower  bowel  possess  a  wide  field  of 
usefulness  in  constipation,  though  they  are  in  some  instances 
fearfully  abused.  For  the  acute  constipation,  numerous 
injections  of  warm  water  and  soap  suds  may  be  employed, 
interspersing  them  with  injections  of  cotton-seed  oil. 
These  injections  should  be  sent  up  high  through  a  colon 
tube,  and,  unless  there  is  a  surgical  condition  present,  will 
suffice  to  overcome  the  constipation. 

In  ordinary  chronic  constipation  the  use  of  small  enemas 
of  warm  water,  or  one  every  day  is  infinitely  preferable  to 
the  daily  use  of  laxative  drugs.  I  generally  allow  my 
patients  to  have  a  fountain  syringe  convenient,  and  to 
use  a  small  enema,  if,  after  an  earnest  effort,  the  bowels  fail 
to  move  alone.  I  believe,  and  have  taught  for  years,  that 
two  or  three  enemas  of  a  pint  each  are  better  and  safer  than 
one  large  enema  of  several  pints.  The  immense  quantities 
of  water  which  some  advocate  are  dangerous,  and  liable  to 
bring  on  intestinal  paralysis. 

In  some  cases  with  accumulation  of  hard  feces  in  the 
rectum,  and  where  the  mucous  membrane  is  dry  and  ex- 
coriated in  places  with  pieces  of  adherent  fecal  matter,  and 
where  the  sigmoid  and  lower  end  of  the  colon  are  sensitive 
to  pressure,  exceedingly  good  results  are  obtained  by 
systematically  washing  out  the  colon  and  rectum  with  one 
or  two  quarts  of  hot  water  containing  a  few  teaspoonfuls 
of  sodium  bicarbonate  or  borax  or  boric  acid.  The  fluid 
should  be  introduced  slowly,  and  at  low  pressure,  while  the 
patient  is  in  the  knee-chest  position.  Following  each  in- 
jection at  night,  from  2  to  4  ounces  of  warm  cotton-seed 
oil  or  olive  oil  may  be  injected  into  the  rectum  and  kept 
over  night.     This  by  antiperistalsis  will  work  up  into  the 


552  CONSTIPATION 

sigmoid  and  colon,  where  it  will  exert  a  softening  effect 
on  the  feces  and  an  emollient  effect  on  the  gut. 

It  is  a  common  custom  of  mine  to  advise  the  injection 
of  warm  cotton-seed  oil  in  quantities  of  2  to  4  ounces  (as 
much  as  can  be  conveniently  retained)  every  night  for  one 
or  more  weeks,  then  every  other  night  for  one  or  more 
months,  and  by  this  I  have  controlled  some  obstinate  cases. 

Glycerin  suppositories,  or  those  made  of  soap,  are  useful 
only  when  the  initial  contraction  of  the  bowel  is  lacking. 

A  most  useful  agent,  lying  on  the  border  line  between  diet 
and  medication,  is  agar  agar.  Studies  made  in  the  labora- 
tory of  L.  B.  Mendel,  of  Yale  University,  have  shown  that, 
whereas  ordinary  carbohydrates  (starches  and  sugars)  are 
very  perfectly  utilized  in  the  alimentary  tract  of  man,  a 
considerable  number  of  unusual  carbohydrates,  such  as 
occur  in  many  seaweeds,  etc.,  are  not  attacked  by  the 
digestive  enzymes.  Experimenting  with  agar-agar,  for 
example,  he  found  that  the  greater  part  was  excreted  in 
the  feces  unchanged.  As  agar  agar  absorbs  water  readily 
and  retains  it,  and  as  it  is  able  to  resist  the  action  of  intes- 
tinal bacteria,  as  well  as  the  enzymes,  its  value  in  the  treat- 
ment of  chronic  constipation  was  suggested.  Its  effect 
on  the  total  mass  of  feces  passed  is  noteworthy,  for  the  agar 
agar  easily  retains  water  in  the  alimentary  residue,  prevents 
the  formation  of  scybalous  masses,  so  characteristic  of 
spastic  constipation,  and  lends  a  soft  consistency  to  the 
whole  stool. 

This  carbohydrate  may  be  begun  with  heaping  tea- 
spoonful  doses,  eaten  with  milk  and  cream  as  with  an 
ordinary  breakfast  food,  and  taken  night  and  morning. 
The  dose  may  be  increased  with  impunity,  if  necessary. 
Generally  regular  movements  will  begin  after  the  agar 
agar  has  been  taken  for  three  or  four  days.  In  the  mean- 
while, the  lower  bowel  may  be  emptied  by  enemas.  This 
preparation  may  be  obtained  in  the  market  under  the  name 
of  "Regulin,"  which,  though  no  better,  is  a  convenient 
form  of  the  agar  agar.     After  the  bowels  move  with  regu- 


DRUG    THERAPY    IN    CONSTIPATION  553 

larity,  the  preparation  may  be  gradually  reduced  until 
none  is  needed. 

Psychotherapy. — This  has  been  fairly  covered  in  the 
chapter  of  that  name,  but  I  may  be  pardoned  for  reiterating 
the  statement  that  the  initial  peristalsis  is  largely  under  the 
influence  of  the  subconscious  personality  of  every  individual. 
If  this  subconscious  power  is  trained  to  exert  its  effect  at  a 
stated,  exact  time,  and  if  this  psychic  agent  is  aware  that 
its  "still  small  voice"  will  be  promptly  heeded,  the  vast 
majority  of  intestinal  musculatures  will  respond  with 
clock-like  regularity  (for  this  power  can  mark  the  time), 
and  the  constipation  can  be  cured  by  this  means  alone. 
This  is  no  fanciful  picture.  It  has  been  demonstrated  time 
and  again. 

Drug  Therapy  in  Constipation. — Before  entering  this 
subject,  let  me  sound  a  warning  note,  for  many  cases  of 
constipation  have  been  caused  by  the  unwise  use  of  drugs. 
A  real  cure  for  constipation  must  first  be  based  upon 
hygiene,  diet,  and  the  physiology  of  peristalsis;  after 
that  may  come  drug  treatment. 

The  medicines  needed  for  the  relief  and  cure  of  this 
symptom  may  be  divided  into  two  classes  in  so  far  as 
rational  prescribing  is  concerned : 

First  those  needed  to  unload  the  bowel  which  has  become 
filled.  In  such  cases  the  proper  drugs  to  use  are  the  various 
purgative  salts,  jalap,  colocynth,  senna,  mercury,  castor 
oil  and  rhubarb. 

Second,  those  that  will  so  influence  the  intestines  as  to 
cause  evacuations  and  produce  normal  activity — that  is, 
drugs  that  will  cure  the  tendency  to  constipation,  rather 
than  give  temporary  relief.  In  these  cases  the  indicated 
drugs  are  such  as  aloes,  cascara,  buckthorn,  phenol- 
phthalein,  sodium  phosphate  and  podophyllin. 

As  some  of  these  drugs  have  certain  peculiarities  in  so  far 
as  their  curative  action  is  concerned,  it  may  be  well  to 
consider  a  few  of  these,  for  the  help  it  will  be  in  rational 
prescribing : 


554  CONSTIPATION 

For  instance,  aloes  and  podophyllin  should  always  be 
prescribed  in  combination  with  some  other  non-purgative 
drugs.     The  reason  is  made  plain  in  the  following  example: 

I^.     Resinse  podophylli gr.  iv. 

Ext.  nucis  vom., 

Ext.  belladonnae aa  gr.  v. 

Ext.  physostigmatis grs.  iii. 

M.  Ft.  pil.  No.  XXX. 
SiG. — One  night  and  morning  as  directed. 

The  object  of  adding  the  non-purgative  extract  of  nux 
vomica  is  because  of  its  peculiar  tonic  and  stimulant  powers 
in  preventing  subsequent  atony  of  the  musculature  and 
increasing  reflex  action,  thus  improving  peristalsis.  This 
should  be  remembered,  as  it  has  an  important  bearing  on 
many  cases  of  chronic  constipation.  The  dose,  however, 
should  be  small. 

The  object  of  adding  the  non-purgative  extract  of  bella- 
donna is  to  depress  the  inhibitory  fibers  of  the  splanchic 
nerves,  to  allay  spasm  and  to  decrease  griping,  all  of  which, 
of  course,  aid  peristalsis.  The  object  of  the  laxative 
extract  of  physostigma  is  to  stimulate  the  unstriped 
muscular  fibers  of  the  intestines,  thus  aiding  the  whole 
prescription. 

When  prescribing  senna,  colocynth,  or  jalap,  remember 
that  they  are  quite  active  purgatives,  and  that  the  reaction 
from  their  effects  is  liable  to  again  cause  the  very  ailment 
that  they  are  being  given  for.  They  should  not  be  used 
except  when  quite  necessary.  Rhubarb  also  should  be 
prescribed  with  care,  for  its  secondary  effect  is  astringent. 
Four  days  of  rhubarb  medication  is  sufficient  for  a  time, 
and  a  week  should  elapse  before  it  is  again  employed. 
This  drug  is  unsuitable  for  regular  administration  in 
constipation. 

Another  drug  that  is  harmful  for  regular  use  is  calomel, 
and'-ut  has  probably  been  more  abused  than  any  other 
cathartic.     For   emptying   the    alimentary    canal    one    or 


TREATMENT   OF   CONSTIPATION  555 

two  times  it  is  useful  and  efficient,  but  for  continuous  use  it 
is  pernicious. 

Among  the  most  dependable  cathartics  for  constipation 
are  cascara  sagrada  (rhamnus  purshiana)  and  phenol- 
phthalein.  The  former  is  best  administered  in  the  form  of 
aromatic  fluid  extract  (dose  fifteen  drops  to  one  teaspoonful) 
or  the  fluid  extract  (dose  ten  to  thirty  drops).  Phenolph- 
thalein  may  be  given  in  doses  of  i  to  5  grains,  seeming  to  act 
as  a  simple  evacuant  of  the  bowels.  This  drug  is  specially 
adapted  for  combination  with  calomel,  and  in  quantities 
as  small  as  i/io  of  a  grain  with  an  equal  amount  of  the 
calomel,  exerts  a  perceptible  effect.  It  is  the  active 
constituent  of  many  of  the  laxative  proprietaries  now  so 
attractively  advertised,  and  many  preposterous  claims  are 
made  for  it. 

For  other  cathartic  prescriptions  the  reader  is  referred  to 
the  chapter  on  drug  therapeutics. 

The  liquid  preparations  of  petroleum  are  coming  into 
popularity  for  internal  administration  for  constipation, 
and  with  some  reason.  Liquid  albolene,  liquid  paraffin, 
and  other  forms  are  now  available,  and  by  the  addition  of 
aromatics,  are  made  palatable.  These  are  suitable  for  the 
spastic  type  and  the  obstruction  type,  especially  when  the 
latter  is  not  too  severe.  In  conditions  of  enteroptosis  or 
membranous  constrictions  of  the  bowels,  the  free  ingestion 
of  these  hydrocarbons  exercises  a  sedative,  antispasmodic, 
lubricating,  and  evacuant  effect.  They  are  best  given  on 
an  empty  stomach,  as  before  meals  or  at  bed  time.  I 
usually  direct  from  one  to  four  teaspoonfuls  before  meals, 
and  double  the  dose  at  bedtime,  regulating  the  dosage  by 
the  effect  produced.  In  many  instances  the  physician  will 
find  it  advisable  to  reduce  the  dose  after  the  bowels  begin 
to  move  with  ease  and  regularity,  instead  of  increasing  it, 
as  required  by  some  other  cathartics. 

A  full  diet,  but  without  irritating  residue  is  indicated  in 
the  obstructive  form  of  constipation,  combined  with  free 
administration  of  the  liquid  petroleum  preparations.     The 


556  CONSTIPATION 

ordinary  cathartics  are  not  so  well  suited,  for,  while  they 
may  empty  the  bowels,  griping  pains  are  generally  suffered 
during  their  action  and  irritation  follows  in  their  wake. 
To  keep  the  intestinal  lumen  well  filled,  so  as  to  promote 
forward  peristalsis,  and  at  the  same  time  to  keep  the 
intestinal  walls  well  lubricated  so  the  fecal  current  may 
move  on  with  the  least  impediment,  is  both  logic  and 
good  therapeutics. 

These  absolutely  failing,  surgery  is  generally  indicated. 

To  thoroughly  relieve  a  sufferer  who  has  long  been 
afflicted  with  chronic  constipation,  and  has  borne  all  its 
burdens,  is  a  most  worthy  achievement  for  any  physician; 
for  to  a  great  extent  it  substitutes  energy  for  languor,  hope 
for  pessimism,  appetite  for  anorexia,  courage  for  timidity, 
and  joy  for  a  previous  settled  gloom.  As  an  emancipated 
patient  once  expressed  himself  to  me,  "each  flower  bears  a 
new  perfume  and  the  skies  are  a  deeper  blue." 


CHAPTER  XXIII 
INTESTINAL  PARASITES 

Many  of  the  animal  parasites  occurring  in  man  inhabit 
the  intestinal  canal.  About  fifty  varieties  have  been  lo- 
cated, but  all  do  not  produce  pathologic  conditions.  Some 
are  harmless  when  first  introduced  into  the  body,  but  may 
later  take  on  pathologic  potentialities;  some  produce  a 
pathologic  state  locally  in  the  intestines  or  by  their  toxins 
in  the  blood;  some  bring  on  anemia  by  causing  small  but 
repeated  hemorrhages  from  the  intestinal  surface.  There 
are  no  characteristic  symptoms  accompanying  the  presence 
of  intestinal  parasites,  but  their  presence  must  be  diagnosed 
by  discovering  either  them  or  their  ova  in  the  stools. 

Many  and  varied  are  the  gastrointestinal  disturbances, 
nervous  manifestations,  and  general  debility  that  may  fol- 
low their  presence;  while  numerous  complications  may 
occur  by  their  migration  to  other  organs. 

These  parasites  may  be  broadly  divided  into  two  classes, 
the  protozoa  and  the  vermes. 

The  methods  of  examination  of  the  stools  in  search  and 
discovery  of  them  have  been  covered  in  the  special  chapter 
on  examination  of  the  feces. 

Among  the  protozoa  are  the  amebse,  whose  examination 
and  treatment  have  been  discussed.  Another  of  the  uni- 
cellular organisms  is  the  coccidium,  which  is  occasionally 
found  in  the  stools.  The  coccidia  are  egg-shaped,  pro- 
vided with  a  thin  shell,  and  contain  in  their  interior  a  large 
number  of  nuclei,  usually  arranged  in  groups.  They  seem 
to  exert  no  ill  effect  upon  the  human  organism. 

The  cercomonas  intestinalis  is  pear-shaped,  with  a  nucleus 
and  eight  flagellae.  The  head  tapers  obliquely,  and  has  a 
depression.     This  organism  seems  to  exert  no  primary  bad 

557 


558  INTESTINAL  PARASITES 

effect,  but  is  claimed  to  prolong  existing  catarrhal  affec- 
tions of  the  intestines. 

Balantidium  Coli.— This  protozoon  has  been  described, 
and  is  capable  of  producing  lesions  similar  to  amebiasis. 
Harlow  Brooks  stated  in  1902  that  an  outbreak  of  dysen- 
tery among  the  orang-outangs  in  the  New  York  Zoological 
Park  was  due  to  this  cause.  From  a  study  of  iii  cases 
reported  with  sufficient  completeness  Strong  concludes 
that  thirty- two  recovered;  and  that,  while  the  mortality 
was  apparently  30  per  cent.,  a  number  of  the  cases  died  of 
other  diseases. 

Treatment. — Quinin  enemas,  as  given  in  amebiasis, 
seem  to  have  been  successful.  Rapid  cure  following  the 
full  ipecac  treatment  has  been  reported  by  Duncan;  also 
the  ordinary  vermifuges  have  apparently  given  good  results 
when  used  energetically. 

VERMES 

The  tapeworms  or  cestodes  are  perhaps  the  most  impor- 
tant of  this  class,  and  have  been  described.  Many  efforts 
have  been  expended  in  discovering  a  specific  treatment  for 
this  parasite,  but  in  some  individuals  it  is  extremely  difficult 
to  expel  the  head,  and  unless  this  is  accomplished  the  worm 
will  continue  to  grow. 

The  male  fern  is  nearer  a  specific  than  any  other  drug, 
and  before  administering  it  the  intestines  should  be  as  com- 
pletely empty  as  possible,  not  only  of  food  and  the  products 
of  digestion,  but  also  of  the  mucus  which  irritation  from  the 
worm  has  caused. 

Consequently,  before  the  anthelmintic  is  administered, 
at  least  two  days  should  be  devoted  to  the  preparation  of 
the  patient  for  the  treatment.  It  is  important  that  for 
these  two  days  the  patient  should  attempt  no  business, 
but  should  attend  to  the  matter  in  hand.  The  diet  should 
be  liquid;  milk,  not  more  than  a  quart,  or  beef  tea  and 
coffee,  if  he  desires.     During  these  two  days  he  should 


TREATMENT   OF   TAPEWORM  559 

receive  a  small  dose  of  salts  three  times  daily,  so  that  the 
upper  portion  of  the  intestines  may  be  thoroughly  cleaned. 
The  following  is  an  eligible  prescription : 

I^.    Magnesii  sulphatis 5ii- 

Spiritus  chloroformi 5iii- 

Aquae q.s.  ad.    5vi. 

SiG. — One  tablespoonf  ul  in  water  three  times  daily  an  hour 
before  meals. 

If  this  acts  painfully,  the  discomfort  may  be  lessened  by 
an  occasional  hypodermic  dose  of  i/io  grain  of  morphin, 
but  the  saline  should  be  kept  up,  if  possible. 

At  bed  time  the  evening  before  the  specific  drug  is  to  be 
administered  the  patient  should  receive  two  tablespoonfuls 
of  the  above  magnesium  sulphate  mixture,  and  if  this  has 
not  acted  well  by  eight  o'clock  the  next  morning,  the  same 
dose  should  be  repeated. 

The  male  fern  should  be  given  as  follows : 

I^.     Oleoresinas  aspidii 5i- 

Ft.  capsule  No.  8. 
SiG. — Four  capsules,  with  half  a  glass  of  hot  water,  at  9 
A.  M.,  and  four  capsules,  with  hot  water,  at  10  A.  m. 
(Important:  before  taking  the  above  capsules,  each 
one  should  be  uncapped.) 

At  twelve  o'clock  three  tablespoonfuls  of  the  magnesium 
sulphate  mixture  should  be  taken  to  insure  the  rapid  passage 
of  the  male  fern  through  the  intestine,  lest  too  much  absorp- 
tion ensue. 

During  the  morning  no  nourishment  should  be  ingested 
other  than  black  coffee,  clear  tea  or  bouillon. 

Except  when  on  the  toilet,  the  patient  should  stay  in  bed 
the  remainder  of  the  day.  Should  faintness  be  felt,  brandy 
or  aromatic  spirits  of  ammonia  may  be  given,  or  a  hypoder- 
mic of  strychnin.  After  i  p.  m.  the  patient  may  take 
light  food,  if  he  desires. 

The  stools  should  all  be  passed  into  receptacles  where 
they  can  be  thoroughly  strained,  in  order  that  the  tape- 


560  INTESTINAL  PARASITES 

worm's  head  may  be  sought.  After  the  above  treatment  it 
will  often  be  found. 

There  are  many  other  remedies  for  this  parasite,  some  of 
which  are  quite  efficient,  and  when  one  is  unsuccessful, 
others  may  be  tried. 

Filmaron,  which  is  said  to  contain  the  teniacide  principle 
of  the  male  fern,  is  useful  in  some  cases.  It  may  be  admin- 
istered in  capsules  of  8  to  15  grains,  and  followed  by  a  saline 
cathartic.  It  should  not  be  given  in  connection  with  fatty 
oils  or  alcohol,  as  they  dissolve  it,  and  may  produce  toxic 
symptoms. 

Pomegranate  root,  in  the  form  of  infusion  of  the  bark,  is 
recommended.  Three  ounces  are  macerated  in  10  ounces  of 
water,  and  given  in  divided  doses  an  hour  or  more  apart. 
This  sometimes  causes  colic. 

The  active  principle  of  the  pomegranate  root,  pelletierin, 
in  4-  to  8 -grain  doses,  with  5  grains  of  tannin  added  to  each 
dose,  has  been  used  by  some  with  satisfaction.  I  have  had 
no  personal  experience  with  it. 

An  infusion  of  pumpkin  seed,  in  which  about  4  ounces 
of  the  bruised  and  macerated  seed  are  boiled  in  water,  is 
quite  efficient.  This  can  be  taken  in  one  or  two  doses,  and 
castor  oil  in  two  hours.  In  one  instance  this  proved  suc- 
cessful in  a  case  under  my  observation,  after  both  male  fern 
and  kamala  had  failed  to  bring  the  head  of  the  tapeworm. 

Turpentine  in  a  i -ounce  dose,  followed  immediately  with 
a  glass  of  milk,  and  two  hours  later  with  a  cathartic,  is 
recommended,  but  I  should  hesitate  to  give  that  quantity  of 
turpentine  at  once. 

Kamala. — This,  too,  in  doses  of  i  or  2  drams,  is  efficient. 
This  sometimes  produces  quite  an  energetic  effect,  and  may 
be  accompanied  by  griping,  nausea,  and  vomiting. 

Benzene  has  been  recommended  by  Hemmeter,  and  Osier 
has  recommended  salol  and  croton  oil. 

The  male  fern,  pumpkin  seed  and  kamala  are  the  best 
remedies. 

Before  leaving  the  subject  of  tapeworm,  let  me  say  that 


ASCARIS    LUMBRICOIDES  56 1 

there  are  no  reliable  subjective  diagnostic  symptoms. 
Indefinite  symptoms  of  malaise,  indigestion,  anemia,  mor- 
bid appetite,  etc.,  are  not  indicative  of  tapeworm,  and  the 
only  true  diagnostic  information  can  be  obtained  by  inspec- 
tion of  the  stools,  and  noting  the  segments  of  the  worm  as 
they  escape  with  the  feces.  In  many  patients  with  tape 
worm  no  symptoms  whatever  are  manifested,  and  I  have 
had  more  than  one  patient  appearing  in  perfect  health  who 
have  noted  pieces  of  tapeworms  in  their  stools,  but  were 
unaware  of  the  trouble  from  other  sensations. 

Distomiasis  or  Fluke  Worms. — These  parasites  are  found 
in  the  lungs,  liver,  small  intestine,  and  in  the  blood;  in 
the  latter  case  affecting  chiefly  the  urinary  system  and 
rectum. 

In  general  the  liver  fluke  is  of  leaf-shape,  and  more  fre- 
quently affects  young  children.  With  this  there  is  gener- 
ally an  irregular  diarrhea  with  pain  and  intermittent  jaun- 
dice, but  not  much  fever.  The  ova  of  the  fluke  are  found  in 
the  stool. 

The  treatment  should  consist  of  male  fern,  as  employed 
for  tapeworm,  for  the  intestinal  manifestations.  Nothing 
has  been  found  effective  for  the  treatment  of  this  parasite 
in  the  blood,  though  Kemp  recommends  hexamethylenamin 
and  sodium  benzoate  in  large  doses  four  times  daily. 

Ascaris  Lumbricoides. — This  nematode,  or  round  worm, 
is  one  of  the  most  commonly  observed  parasites  in  man.  It 
occupies  the  upper  part  of  the  small  intestine,  and  usually 
not  more  than  two  are  present,  though  in  some  patients  they 
have  been  found  in  enormous  numbers. 

Infection  usually  takes  place  by  eggs  in  the  soil  near 
dwellings,  in  drinking  water,  and  especially  in  raw  foods,  as 
salads  and  fruits.  The  lumbricoid  worms  are  more  often 
observed  in  children  from  three  to  twelve  years  of  age,  and 
are  seldom  found  in  adult  males. 

The  worms  sometimes  crawl  into  the  stomach,  whence 
they  may  be  ejected  by  vomiting,  or  they  may  even  crawl 
up  the  esophagus  and  mouth.  Cases  are  on  record  where 
36 


562  INTESTINAL  PARASITES 

this  worm  has  entered  the  larynx,  producing  fatal  asphyxia, 
or  into  the  trachea,  producing  gangrene.  Appendicitis  has 
been  attributed  to  this  parasite,  and  obstruction  of  the 
bowel  has  been  brought  on  by  large  masses. 

Diagnosis. — There  may  be,  and  often  are,  no  special 
symptoms.  Children  may  be  restless  in  sleep,  with  picking 
at  the  nose,  grinding  teeth,  and  twitching  muscles,  or  even 
convulsions.  The  only  positive  diagnosis  can  be  made  from 
finding  the  worm,  or  detecting  its  ova  in  the  stools. 

Treatment. — It  is  well  to  administer  a  saline  purge 
before  giving  an  anthelmintic,  and  withholding  solid  food 
for  twenty-four  hours.  Santonin  combined  with  calomel, 
seems  to  be  the  most  effective  remedy.  This  drug,  in  doses 
of  one-half  to  one  grain  for  a  small  child,  and  2  or  3  grains 
for  an  adult,  may  be  given  in  two  doses,  and  followed  in 
six  hours  by  a  full  dose  of  castor  oil. 

Chenopodium,  in  doses  of  15  to  30  grains  of  the  powdered 
seed,  or  two  to  ten  drops  of  the  oil,  followed  by  a  cathartic, 
has  proved  effectual. 

The  patient  or  family  must  be  informed  that  santonin 
may  be  followed  by  orange  yellow  urine  or  yellow  vision, 
lest  uneasiness  be  felt,  if  these  symptoms  appear. 

Oxyuris  Vermicularis  (Thread -worm,  Pin-worm). — These 
are  small  thread-like  worms,  which  infest  the  rectum,  and 
often  find  their  way  into  the  vagina. 

Diagnosis. — These  worms  produce  almost  intolerable 
itching  and  irritation  about  the  anus,  interfering  with 
sleep,  and  rendering  the  patient  nervous  and  irritable. 
The  little  worms  are  easily  recognized  in  the  stools. 

Treatment.— Santonin  may  be  administered  as  for 
ascaris,  to  remove  them  from  the  upper  bowel,  should 
they  be  there. 

Local  means  are  generally  effectual  in  expelling  them  from 
the  rectum,  where  they  are  the  most  annoying.  Enemas  of 
water  containing  a  small  amount  of  benzene  or  vinegar 
seem  useful.  A  very  popular  remedy  is  the  infusion  of 
quassia,   which  has  been  employed  for  many  years.     In 


DIAGNOSIS    OF    TRICHINA  563 

my  own  practice  I  have  found  the  injections  of  kerosene 
oil  more  satisfactory  than  anything  else,  and  have  rarely 
needed  to  direct  the  second  injection. 

Trichina  Spiralis. — The  trichina  when  fully  grown  is 
found  in  the  small  intestine,  though  the  embryos  pass  from 
the  intestines  and  reach  the  voluntary  muscles,  where  they 
may  become  encapsulated. 

Their  etiology  has  been  fully  discussed,  being  produced 
by  the  eating  in  man  of  the  raw  or  incompletely  cooked 
flesh  of  trichinous  hogs. 

Diagnosis. — Patients  infected  with  this  parasite  suffer 
from  gastrointestinal  disturbances,  as  pain  in  the  abdomen, 
anorexia  and  vomiting,  or  even  diarrhea.  These  symptoms 
have  been  so  marked  as  to  cause  the  suspicion  of  typhoid 
fever  or  cholera  nostras ;  for  with  the  other  symptoms  may 
be  an  intermittent  or  remittent  fever  of  marked  degree. 
Pain  and  swelling  are  present  in  the  muscles.  The  general 
nutrition  is  much  disturbed,  and  both  emaciation  and 
anemia  supervene. 

The  intestinal  worms  are  visible  to  the  naked  eye,  being 
white  and  glistening,  with  a  thickened  caudal  extremity 
armed  with  two  little  projections.  They  can  also  be  found 
in  the  muscles. 

Treatment. — ^This  consists  of  gastric  lavage,  and  free 
evacuation  of  the  bowels.  Thymol,  santonin,  aspidium, 
kamala,  and  the  other  recognized  anthelmintics  are  indi- 
cated. Later  on  the  treatment  is  symptomatic  and  sup- 
portive. Kemp  recommends  hexamethylenamin  and  so- 
dium benzoate  four  times  daily. 

Tricocephalus  Dispar  (Whip -worm). — This  worm  infests 
the  cecum  and  large  intestine  of  man,  and  is  easily  recog- 
nized by  the  peculiar  differences  between  the  anterior  and 
posterior  portions.  The  anterior  forms  three-fifths  of  the 
body,  is  thin  and  hair-like,  that  of  the  male  being  rolled  like 
a  spring.  The  number  of  worms  is  variable,  as  many  as 
twenty  thousand  having  been  counted.  These  parasites 
are  common  in  Europe,  but  up  to  two  or  three  years  ago 


564  INTESTINAL  PARASITES 

they  were  rarely  found  in  the  United  States.  They  are 
fairly  prevalent  now. 

Diagnosis. — This  can  be  made  from  the  peculiar  ova,  as 
living  worms  are  rarely  found  in  the  stool.  The  ova  are 
lemon  shaped,  dark  brown,  and  have  button-like  projections. 

Treatment. — Either  thymol  or  male  fern  seems  effective, 
and  high  enemas  of  water  containing  a  little  benzene,  or  the 
high  enemas  of  kerosene  oil  may  be  employed. 

Uncinariasis  (Hookworm  Disease,  Ground  Itch  Anemia). 
— This  is  probably  the  most  important  and  destructive  of 
the  intestinal  parasites.  For  man,  two  different  species 
are  known,  namely  the  New  World  form  (Necator  Ameri- 
canus,  or  American  murderer)  and  the  Old  World  form 
(Anchylostoma  duodenale).  The  vast  majority  of  cases  in 
the  United  States  are  due  to  the  New  World  hookworm; 
but  occasionally  cases  caused  by  the  Old  World  parasite  are 
found  among  immigrants  or  native-born  Americans  who 
have  lived  abroad. 

The  hookworm  is  a  slender  worm,  about  1/2  inch  long 
and  scarcely  thicker  than  a  small-sized  hairpin.  It  at- 
taches itself  to  the  intestinal  walls,  wounds  the  mucosa, 
sucks  the  blood,  eats  the  epithelium,  and  according  to 
present  evidence,  it  apparently  produces  a  poisonous  sub- 
stance which  injures  the  host. 

To  C.  W.  Stiles  we  owe  much  of  our  pioneer  information 
concerning  this  parasite,  and  in  his  bulletin,  published  by 
the  Public  Health  and  Marine-Hospital  Service,  is  found  a 
most  complete  discussion  of  the  subject. 

Hookworm  disease,  as  might  be  expected  from  its  African 
origin,  is  most  common  where  the  negro  is  most  numerous. 
Through  ages  of  infection  the  black  man  has  acquired  an 
almost  perfect  racial  immunity  from  the  effects  of  the  para- 
site, but  this  in  no  way  interferes  with  the  fact  that  he 
frequently  harbors  a  large  number  of  the  worms.  The 
negro,  coming  in  contact  particularly  with  the  poorer  class 
of  white  people,  is  liable  to  infect  them,  and  this  parasite, 
gaining  a  foothold  in  the  new  host,  saps  both  life  and  vital- 


DIAGNOSIS    OF    UNCINARIASIS  565 

ity,  preventing  normal  mental  and  physical  growth. 
Thus  hookworm  disease,  by  its  enervating  effect  has 
become  both  a  medical  and  sociologic  problem. 

Diagnosis. — ^There  are  three  methods  of  diagnosing  hook- 
worm disease,  according  to  Stiles — namely,  by  microscopic 
examination  of  the  feces  to  find  the  eggs;  by  judging  the 
symptoms;  and  by  experimental  treatment,  and  finding 
the  expelled  worms  in  the  stools. 

It  is  rare  that  the  adult  worms  are  seen  in  the  feces  except 
during  treatment,  but  the  stools  of  hookworm  cases  con- 
tain the  characteristic  eggs  of  the  parasite,  and  by  finding 
these  a  positive  diagnosis  can  be  made.  The  various 
Southern  state  boards  of  health  and  the  Hygienic  Labora- 
tory of  the  U.  S.  Public  Health  and  Marine-Hospital  Service 
make  these  examinations  free  of  charge. 

For  ordinary  purposes  the  following  technic  is  sufficient : 
Patients  are  instructed  to  furnish  about  half  an  ounce  of 
their  fresh  fecal  material.  A  small  portion  of  this  is  taken 
up  on  the  flat  end  of  a  toothpick  (using  a  separate  toothpick 
for  each  specimen),  and  smeared  on  a  slide  in  a  drop  of 
water;  and  in  hot  weather  or  when  the  feces  are  specially 
offensive,  trikresol  is  better  than  water.  The  smear  should 
be  uniform  and  not  too  thick,  with  neither  staining  nor 
drying.  A  cover-glass  is  placed  over  the  smear,  and  the 
preparation  is  examined  under  an  8-millimeter  or  1/3- 
inch  objective.  In  heavy  infections  the  eggs  will  usually  be 
found  on  the  first  slide,  but  at  least  ten  such  preparations 
should  be  examined  before  a  negative  opinion  is  expressed. 
Stiles  claims  that  it  takes  thirty  to  sixty  minutes  to  prop- 
erly examine  ten  such  slides. 

If  free  embryos  are  present  in  the  fresh  feces  the  probabil- 
ity is  that  the  Strongyloides  stercoralis  is  there.  The 
beginner  may  also  be  confused  by  various  vegetable  cells 
which  he  mistakes  for  eggs,  or  by  plant  hairs,  which  he 
mistakes  for  embryos.  Strawberry  hairs  are  specially 
liable  to  cause  mistakes. 

Bass  has  recently  suggested  a  method  of  concentrating 


566 


INTESTINAL   PARASITES 


these  ova,  by  using  salt  solution,  or  preferably,  calcium 
chlorid,  in  a  solution  slightly  heavier  in  specific  gravity  than 
are  the  eggs. 

The  recognition  of  well-marked  cases  by  symptoms  is 
generally  easy  for  an  experienced  observer,  but  should  not 


Fig.  85. — View  of  a  floor-privy,  tub  system.     (Hookworm  Bulletin,  Georgia 
State  Board  of  Health.) 


be  depended  on  alone.  These  are  dry  hair,  dry  skin, 
dilated  pupils,  tenderness  in  epigastric  region,  winged 
shoulder-blades,  shoulders  sloping  down  and  forward,  slow 
speech,   tallow-like  skin,   under-developed  bodies,   general 


PROPHYLAXIS 


567 


anemia,  scant  pubic  and  axillary  hair,  delayed  menstrua- 
tion, and  a  history  of  ground  itch. 

Prophylaxis. — Those  infected  should  be  treated,  as  every 
one  is  a  source  of  danger.  It  is  better  to  carry  on  the  treat- 
ment in  the  fall  and  winter  months,  lest  summer  treatment 


Fig.  86. — A  floor-privy,  pail  system,  closed  in  back.     (Hookworm  Bulletin, 
Georgia  State  Board  of  Health.) 


be  only  temporary  in  freeing  from  the  embryos  the  ground 
around  the  farm  houses.  All  persons  living  in  infected 
localities  should  be  cautioned  concerning  coming  in  direct 
contact  with  pools  of  water  on  the  ground  or  moist  earth. 


568  INTESTINAL  PARASITES 

All  should  wear  shoes,  and  children  should  not  be  allowed 
to  play  out  of  doors  except  at  some  distance  from  the  house. 
It  is  important  to  prevent  indiscriminate  scattering  of 
feces  in  the  yard,  around  the  barn,  or  in  the  orchards,  for 
the  provision  of  properly  constructed  water  closets  or 
privies  in  rural  localities  is  of  the  greatest  aid  in  prevent- 
ing the  spread  of  hookworm  disease.  Finally,  the  feces 
having  been  passed  into  some  proper  receptacle  completely 
protected  from  flies  and  all  animals,  at  intervals  should  be 
carried  to  a  suitable  place  and  buried.  The  time  and 
trouble  taken  by  these  precautions  do  not  compare  in  the 
least  with  the  suffering,  invalidism,  and  death  that  may 
result  from  indifference,  not  to  say  the  pecuniary  loss  occa- 
sioned by  the  inaptitude  or  inability  of  these  victims  to 
perform  labor.  Well  has  the  hookworm  infection  been 
called  the  "lazy  disease." 

Treatment. — The  following  treatment  promulgated  by 
the  Georgia  State  Board  of  Health  is  simple  and  effective, 
and  has  given  me  almost  uniform  good  results: 

The  diagnosis  having  been  established,  the  patient  is 
consulted  as  to  the  day  of  the  week  that  can  be  most  easily 
spared;  and  in  many  instances,  as  in  mill  operatives,  it  will 
be  Sunday. 

On  the  day  before  the  treatment  is  to  be  begun  the 
patient  is  advised  to  eat  little  dinner  and  no  supper.  Late 
in  the  afternoon  he  is  given  a  full  dose  of  calomel,  the 
amount  varying  from  2  to  5  grains,  depending  upon  the 
age  and  strength  of  the  patient.  Castor  oil  is  not  advis- 
able. If  the  calomel  acts  freely  during  the  night  no  other 
purgative  is  needed  on  the  following  morning,  but  if  not, 
a  full  dose  of  magnesium  sulphate  should  be  given  in  hot 
water  on  awaking.  After  the  bowels  have  freely  acted, 
finely  powdered  thymol  in  capsules  is  then  given,  the  quan- 
tity depending  on  the  age  and  strength.  It  is  well  to  be 
guided  by  the  apparent  age  of  the  patient  rather  than  the 
given  age,  as  many  of  these  unfortunates  appear  as  much 
as  six,  eight,  or  ten  years  younger  than  they  really  are. 


TREATMENT    OF    UNCINARIASIS  569 

The  dose  of  thymol  should  be  divided  into  two  equal 
parts,  the  first  half  being  given  at  once,  and  the  second  at 
the  expiration  of  an  hour.  Following  the  administration  of 
the  medicine  the  patient  should  be  instructed  to  remain  in 
bed.  Lying  on  the  right  side  will  assist  the  drug  to  pass 
quickly  into  the  intestine  from  the  stomach.  The  amount 
of  thymol  to  be  given  is  as  follows : 

Up  to  five  years  of  age 10  to  15  grains. 

From  five  to  ten  years 15  to  30  grains. 

Ten  to  fifteen  years 30  to  60  grains. 

Fifteen  and  over 60  grains. 

The  patient  should  be  allowed  neither  breakfast  nor 
dinner  on  the  day  of  the  treatment,  though  one  or  more 
cups  of  coffee  may  be  permitted.  If  no  ill  effects  are 
experienced  from  the  thymol,  it  is  well  to  put  off  the  admin- 
istration of  a  laxative  until  four  or  five  o'clock  in  the  after- 
noon, at  which  time  a  saline  should  be  given  in  hot  water. 
After  the  bowels  have  acted  well  the  patient  may  be  allowed 
to  have  food. 

When  this  treatment  is  carried  out  faithfully  it  is  rarely 
necessary  to  repeat  it,  though  it  is  well  after  two  weeks  to 
have  the  feces  examined,  and,  then,  if  thought  advisable, 
the  treatment  can  be  repeated. 

It  is  of  special  importance  that  no  castor  oil  or  other  oils 
should  be  taken  on  the  day  of  the  treatment,  lest  by  dis- 
solving the  thymol  and  aiding  in  its  absorption,  dangerous 
symptoms  might  develop. 

After  the  parasites  are  destroyed,  iron  tonics  and  nutri- 
tious food  will  soon  make  a  surprising  change  in  these 
woe-begone  sufferers,  and  in  many  instances  their  stunted 
frames  will  take  on  a  new  growth,  and  a  fresh  impetus  will 
be  given  their  impaired  mentalities.  The  physician,  who 
thus  discovers  this  infection  in  his  particular  locality,  and 
by  properly  directed  prophylaxis  and  treatment  banishes 
it,  enlarges  his  field  from  that  of  a  medical  man  to  that  of  a 
public  benefactor. 


INDEX 


A 


Abderhal den's  test,  472 
Abdomen,  cleansing  and  shaving  of, 
229 
counter-irritation  over,  215 
examination  of,  12 

Qby  inspection,   16 
flabby,  malign  influence  of,  223 
irritation  of,  275 
local  treatment  of,  203 
neurasthenic  conditions  in,  213 
palpation  of,  29 
upward  traction  on,  229 
X-ray  examination  of,  no 
Abdominal  bandage,  zinc  oxid  plas- 
ter, 231 
compresses,  268,  269 
disease,  border-line  cases  of,  159 
hyperesthesia,  312 
massage,  219 

operations,  peritonitis  after,  436 
pain,  spasmodic,  37 
pressure,  8 
relaxation,  30 

soreness  as  symptom  of  ame- 
biasis, 537' 
supporter,  223,  224 
sympathetic  system,  205 
viscera,  abnormalities  of,  157 
general  ptosis  of,  163 
support  of,  231 
walls,  support  of,  222 
Abscess,  appendiceal,  165 
of  stomach,  482 
periduodenal,  491 
peritoneal,  409 
subphrenic,  443 
Abscesses  from  oxyuris  vermicularis, 
88 
in  right  iliac  fossa,  38 
Absorption  from  intestines,  304 
Acetic  acid  test,  54 
Acetphenetidin  in  neuralgia,  369 
Acetylsalicylic  acid,  369 
Achroodextrin,  58 
AchyHa  gastrica,  415 

application  of  cold  in,  271 
as  a  pure  neurosis,  395 
diet  in,  333,  421 
duodenal  feeding  in,  342,  343 


Achylia  gastrica,  functional,  416 
in  active  physician,  416 
in  old  callous  ulcer,  123 
senile,  47,  357 

test-meal  for  diagnosis  of,  118 
of  pernicious  anemia,  475 
with  stagnation,  474 
Acid  dyspepsia,  488 
index,  high,  333 
Acidity,  gastric,  effect  of  alkalies  on, 

351 
of  gastric  contents,  51 
with  frothy  diarrhea,  353 
Acidol  in  gastritis,  422 

in  senile  achylia,  357 
Acids,  administration  of,  356 

volatile,  in  gastric  filtrate,  54 
Adalin  as  hypnotic,  368 
Adenocarcinoma,  461 
Adhesions  in  intestines,  545 
perigastric,  219 
protective,  491 
Adhesive  bandage,  removal  of,  230 
bands  in  intestines,  513 
plaster  belt,  433 

for  support,  228,  229,  231 
Adler's  benzidin  test,  61 
Aerophagia,  301 

carminatives  in,  302 
Agar-agar  as  evacuant,  362 

in  chronic  constipation,  552 
for  distention  of  bowels,  168 
in  intestinal  stenosis,  512 
Age,  apparent,  in  hookworm  disease, 

568 
Agglutination  tests,  108 
Air,  swallowing  of,  301,  364,  401 
Akoria  differentiated  from  bulimia, 

386 
Albolene  in  treatment  of  cancer,  480 
liquid,  as  laxative,  168,  362,  555 
in  cardiospasm,  382 
Albright's  rectal  irrigator,  238 
Albumen,  absorption  of,  344 

loss,  330 
Albuminous  food,  daily  requirement 

of,  319 
Alcohol,  abstention  from,  424,  425, 

452 
as  cause  of  gastritis,  409,  410 
in  predigested  foods,  349 


571 


572 


INDEX 


Alcohol   in   proprietary   foods,    337, 
338,  339 

prohibited,  334 
Alcoholic  coma  in  infants,  338 

debauch,  gastric  lavage  for,  268 

gastritis,   423 
Alcoholism,  acute,  emesis  in,  366 
Alimentary  canal,  compensation  in, 

324 
hypersecretion,  389,  395 
tract,  effects  of  vibration  in,  212 
study  of,  109 
upper,  bleeding  from,  167 
Alimentation,  duodenal,  339,  340 
Alkalies,  combinations  of,  352 

effects  of,  351 
Alkaline  antiseptic  liquids,  199 
mineral  waters,  423 
powders  and  liquids,  355 
treatment  of  hyperchlorhydria, 

390 

waters,  American,  355,  356 
Allison  table  for  rectal  therapeutics, 

Alom  test  for  blood,  60 
Alternate  douche,  268,  269 
Ameba  coh,  79,  526 

as  cause  of  dysentery,  278 
dysenterise,  79,  526 

examination  of,  80 
conditions  in  which  found,  82 
destruction  of,  538,  541 

by  ipecac,  540 
in  stools,  527,  557 
in  the  soil,  527 
Amebiasis,  527,  534 

diagnostic  sign  of,  537 
moderately  severe,    535 
mortality  in,  537 
Amebic  dysentery,  79,  494,  526 
bismuth  treatment  in,  541 
diagnosis  of,  533 
duration  of,  534 
drug  therapy  in,  538 
hemorrhages  in,  535 
prevalence  of,  542 
surgery  in,  541 
treatment  of,  538 
_  types  of,  535 
American  murderer,  102,  564 
Amidulin,  58 
Ammonio-magnesium  phosphate  in 

feces,  74 
Amylodextrin,  58 
Amylopsin,  tests  for,  67 
Anamnesis  in  digestive  diseases,  4 
Anchylostoma  duodenale,  99,  lOi 
Anemia  accompanying  achylia,  416 
accompanying  ulcer,  448 
advancing,  389 


Anemia     caused    by    anchylostoma 
duodenale,  loi 

from  Bothriocephalus  latus,  416 

from  diarrhea,  525 

from  hemorrhage,  442,  557 

from  intestinal  parasites,  557 

ground  itch,  564 

in  cancer,  475 

pernicious,  serum  test  for,  473 
Anesthesia  as  aid  to  examination,  30 

in  gastroscopy,  25 

vomiting  centers  after,  436 
Anesthesin,  367 

Anesthetic  in  rectal  examination,  238 
Aneurysm  of  large  arteries,  171 

of  the  celiac,  476 
Anger  as  cause  of  indigestion,  293 
Angle  worms  eaten  by  epicures,  286 
Anguillula  stercoralis  et  intestinalis, 

.95 

Angulations  of  intestines,  545 
Animal  food  consumed  under  neces- 
sity, 286,  287 
Ankylostoma   duodenale,  564.      See 
also  A  nchylo stoma  duodenale. 
Anorexia  in  gastric  cancer,  465 
nervous,  6,  269,  386 
relief  of,  359 
Antacids,  use  of,  352,  354 
Anthelmintics,      administration     of, 

.370 
Antibodies  in  cancer  serum,  472 
Antiemetics,  366 
Antiferments,  365 
Antigens,  action  of,  472 
Antiperistalsis,  112 
Antiquity,  influence  of  emotions  in, 

282 
Antiseptic  enemas,  251 

lavage,  433 
Antiseptics,  intestinal,  364 
Antrum,  obliteration  of,  121 
Anus,  artificial,  formation  of,  541- 
constriction  of,  507 
fissure  of,  235,  275,  276,  507 
itching  of,  from  worms,  562 
patulous,  252 
puffiness  of,  498 
soreness  of,  507 
Aorta,  aneurysm  of,  38 
pulsating,  457,  475 
Apepsinia,  56 
Aphthous  ulcers,  13 
Apomorphin  hydrochlorid,  366 
Appendicitis  a  cause  of  hyperchlor- 
hydria, 377 
acute,  163 

hydrotherapy  in,  279 
treatment  of,  279 
differential  blood  count  in,  164 


INDEX 


573 


Appendicitis  differentiated  from  hy- 
peracidity, 389 
enteroliths  in,  78 
facial  expression  in,  165 
fulminating  type,  164 
recurrent,  165 
relapsing,  163 
treacherous  nature  of,  165 
Appendix,  rectal  injection  of,   149 
Appetite,  aids  to,  358 

and  food  supply,  321 
and  mental  state,  294 
consideration  of,  6 
in  gastric  neuroses,  401 
juices,  283,  292 
morbid,   561 
vicious,  320 
Apple  dumpling,  phobia  for,  289 
Apples,    unpeeled,  for    constipation, 

550 
Area  of  dulness,  20,  21 
of  resistance,  165 
Areolar  tissue,  destruction  of,  509 
Armed  tapeworm,  89 
Aroma  from  body,  304 
Arterio-sclerosis,  advanced,  171 
Artificial  foods,  336 
Asafetida  enema,  271,  280 
Asbestos    conducting  tube,   257 
Ascaris  lumbricoides,  85,  561 

lumbricoides,     infection     from, 
561 
obstruction  of  bowels  by,  562 
ova  of,  99,  561 
Ascending  colon,  tenderness  of,  535 
Asiatic  cholera,  106 

diagnosis  of,  108 
stools  in,  107 
Asphyxia,     fatal,  ■  from     worm     in 

larynx,  562 
Aspidium,    administration     of,    370. 

See  also  Male-fern. 
Aspiration  of  duodenum,  245 

of  stomach  contents,  179,  181 
Aspirin  for  neuralgia,  369 
Asthenic  gastritis,  411 
Astringents,  369 

vegetable,  370 
Atony,  intestinal,  due  to  enormous 
enemas,  249 
of  cecum,  155 
of  stomach,  21,  137,  163,  426 

medical  treatment  of,  429 
treated  by  gyromele,  215 
X-ray  diagnosis  of,  427 
Atrophic  gastritis,  411 

diet  in,  477 
Auscultation  of  stomach,  17,  19 
Autointoxication,   intestinal,   6,   298 
Autolavage  by  water  emesis,  365 


Automassage,  220 

for  atonic  constipation,  550 

Autosuggestion    and    bowel    move- 
ments, 295 

Autotoxicoses,  vicarious  elimination 
of,  519 

B 

Bacillary  dysentery,  108,  526 

diagnosis  of,  527 
Bacillus  aerogenes  capsulatus,  104 
bifidus,  104 
coli,  104,  106 
comma-shaped,  106 
diphtheriae    as    cause  of  dysen- 
tery, 528 
dysenterise,  527 
lactis  aerogenes,  104 
prodigiosus,  480 
putrificus,  104 
pyocyaneus,  104 
tetani,  105 
tuberculosis,  105 
typhosus,  105 
Bacteria,  indol-forming,  267 
in  feces,  543 

in  intestinal  canal,  330,  552 
Balantidium  coli,  82 

in  intestines,  558 
"Ballooning"  of  intestine,  303 
of  abdomen,  512 
the  rectum,  346 
Barley  flour  as  substitute  for  milk,  341 
Bassler's  electrode,  207 

corset,  225,  226 
Bath,  neutral,  278 
Bathing,  prevention  of,  a  depriva- 
tion, 228 
Beach  rectal  tube,  236 
■  Bedpan,  use  of,  530 
Beef  juice,  value  of,  338 

tapeworm,  90 
Belchings,  5000  in  24  hours,  301 
Belladonna  as  sedative,  367 
Benefit  from  exploratory  operation, 

168 
Benzine  enema,  562 
Beverages,    chemic   composition   of, 
327 
interdiction  of,  during  ulcer,  445 
Bicarbonate  of  soda  in  gastric  acid- 
ity, 35 1  ,      . 
Bile,  appearance  of,  after  laborious 
vomiting,  62 
duct,  calculi  in,  151 

catarrh  of,  363,  365 
inspissated,  68 
in  the  stomach,  62 
obstruction  of,  68 


574 


INDEX 


Biliary  calculi,  calcareous,    151 
cholesterin,  151 
radio-diagnosis  of,  146,  151 
colic,     gastritis      differentiated 
from,  404 
Biliousness,  gastric  analysis  in,  413 
Binder,  electric,  272 
Bismuth  bolus  enema,  152 
coating  of  ulcer,  443 
column  in  cancer,  473 

location  of,  444 
crust,  formation  of,  453 
in  gastric  ulcer,  452,  453 
meal,  112,  118 
outline,  474 
residue,  117 
shadows,  139 
shown  in  skiagram,  139 
Bitter  medicines,  use  of,  384 
Bladder,  irritation  of,  495 
Bland  food,  283 
Blanket  pack,  270,  272 
Blastomycetes  in  stools,  104 
Blood  count,  differential,  164 
in  appendicitis,  164 
excrementitious    substance    in, 

298 
in  gastric  contents,  59,  62 
detected  by  spectroscope,  61 
origin  of,  62 
in  stools,  74 

occult,  in  gastric  contents,  59 
-pressure,  171 
lowering  of,  224 
raised  by   adrenalin   chlorid, 
440 
swallowed  during  sleep,  439 
Blue  color  of  face,  172 
Blushing,  cause  of,  302 
Boas-Oppler  bacillus,  415,  431,  432, 

463,  466,  470 
Boas'  resorcin-sugar  test,  50 
stool-sieve,  76 
test-breakfast,  45 
for  lactic  acid,  53 
"Bodily  housekeeping,"  267 

nutrition  and  mastication,   334 
uplift,  402 
Body,  effluvia  from,  304 

underdeveloped,    in    hookworm 

disease,  566 
weight  and  calories,  323 
Boer  war,  dysentery  and  typhoid  in, 

526 
Bolting  of  food,  335 
Borborygmus,  303 
Bothriocephalus  latus,  91 
Bougie,  esophageal,  26 

contraindications  for,  29 
BouUlon  as  a  medium,  106 


Bowel,  cold  fluid  into,  250 

evacuation,    artificial,    once    in 
two  months,  299 
once  in  two  weeks,  299 
investigation  of  condition  of,  9 
lower,  examination  of,  31 
malignant  disease  of,  243 
movements,  formed,  521 
habit  of,  515,543 
regularity  in,  553 
obstruction  of,  547 
by  worms,  562 
shelves  and  pouches  in,  299 
tortuous  kinking  of,  163 
waking  stimulus  in,  296 
Bradyphagia,  334 
Brain,  cysticerci  in,  90 
Bread  pills,  294 

Breath,  offensive,  304,  364,  412 
Brinkerhoff's  rectal  speculum,  237, 

495  . 
Bromides,  action  of,  367 
Bronchitis  with  emphysema,  171 
Bubbling  sounds,  145 
BuUmia,  385 

Burning   sensation   in    epigastrium, 
385,  388,   392,  394 
in  rectum,  496,  507 
Burns  as  cause  of  diarrhea,  518 

as  cause  of  duodenal  ulcer,  490 
from  radium,  211 
Burrowing  of  acrid  exudate,  509 
Business  man  as  prey  to  indigestion, 

4 
Butter  as  cause  of  diarrhea,  287 

as  cause  of  sitophobia,  288 

to  increase  flesh,  341 
Buttermilk  injections,  157 

lactone,  393 
Buttock,  subtegumentary  cavity  in, 

509 

Butyric  acid  in  gastric  contents,  54 


Cachexia  in  gastric  cancer,  467,  478 

marked,  160,  171 
Calculus,  biliary,  opacity  of,  151 
Calomel,  abuse  of,  554 

action  of,  361 

in  hookworm  disease,  568 
Caloric  absorption  by  rectum,  345 

balance,  disturbance  of,  289,  290 

bankruptcy,  11,  202 

loss  by  lavage,  201 

requirement,  317,  318 
Calories,  deficiency  of,  in  predigested 
foods,  337 

in  cereals  and  vegetables,  326 

in  dairy  products,  326 


INDEX 


575 


Calories  in  fish,  325 

in  fruits,  nuts,  sugar,  327 

in  meats  and  game,  325 

in  soups  and  beverages,  327 
Calorimeter,  322 

Cancer,  analysis  of  30,000  cases  of, 
460 

as  indicated  by  lactic  acid,  54 

cure  serum,  479 

dietary,  477 

differentiation  of,  472 

early  diagnosis  of,  471 

enzyme,  471 

ferment,  470 

in  girl  of  14,  460 

inoperable  diffuse,  475 

juice,  462 

of  cardia,  466 

of  duodenum,  35 

of  esophagus,  544 

of  pylorus,  34,  462 

of  the  stomach,  diagnosis  of,  464 
by  gastroscopy,  469 
symptoms  of,  415,  465 

X-ray  examination  for,  473 

of  uterus,  462 

on  base  of  ulcer,  443,  457 

on  scar  of  ulcer,  445,  461 

patient,  serum  of,  472 

serum  diagnosis  of,  472 

victim,  aid  to,  481 
Cancorin,  479 
Cancrodin,  479 
Cannon  ball  massage,  218 
Carbohydrates,  316,  317 

in  liquid  form,  328 

in  mushes  and  soups,  328 
Carbonic  acid  gas  as  an  aid  to  diag- 
nosis, 20 
gas,  inflation  with,  33 
waters,  273,  422 
Carcinoma,  diagnosis  of,  118,  473 

diffuse  contracting,  118 

from  previous  ulcer,  457 

inoperable,  121,  123 
X-ray  therapy  in,  210 

medullary,  461 

of  esophagus,  112 

of  pylorus,  diet  in,  477 

simulated  by  aneurysm,  476 
surgical  cure  of,  477 

of  stomach,  115,  129 
odor  from,  47 

recurrence  of,  480 

ventriculi,  differential  diagnosis 

of,  475 
prognosis  of,  476 
Cardia,  carcinoma  near,  119 
closure  of,  436 
congestion  at,  130 


Cardiac  neuroses,  171 
Cardialgia,  384 
Cardiospasm,  382 

electrical  treatment  of,  210 
Carlsbad  water,  356,  454 

in  ulcer,  452 
Carminative  enemas,  250 

infusions,  364 
Carminatives,  355,  363 
Cascara  sagrada,  action  of,  361 

in  constipation,  555 
Cast  of  intestines,  397 
Castor  oil  as  evacuant,  361 
Catarrh,  fatal,  from  balantidium  coli, 

85 
Catarrh  of  stomach,    chronic,  410, 

diagnosis  of,  412 
Catarrhal  gastritis,   chronic,  lavage 
in,  418 

symptoms  of,  411 

course  of,  414 

differentiation  of,  415      _ 

microscopical    examination    in, 
414 
Catfish  as  cause  of  sitophobia,  288 
Catharsis  without  griping,  363 
' '  Cathartic  habit  ,"418 

prescriptions,  363 
Cathartics,  action  of,  360 

drastic,  361,  362 
Cats  as  food,  287 
Cecal  ptosis,  546,  547 
Cecum,  atony  and  dilatation  of,  155 

growths  in,  38 

parasite  in,  93 
Celestins- Vichy  in  ulcer,  451 
"Cell-hunger,"  voicings  of,  6 
Cercomonas  intestinalis,  557 
Cereals,  chemic  composition  of,  326 
Cestodes,  88.      See  also  Tapeworm. 
Change,     environmental,     benefits 

from,  309,  356 
Channels,  subtegumentary,  diagram 

of,  501 
Charcot-Leyden  crystals,  75 
Cheerful  companionship,  310 
Chemic  classification  of  food,  316 

examination  of  gastric  contents, 
388 

findings  in  cancer,  normal,  470 
Children,  fluke  worms  in,  561 

parasites  in  stools  of,  104  1 

tuberculosis  in,  105 
Chilly  sensations,  165 
China,  flesh  used  for  food  in,  285 
Chittenden's  dietetic  views,  319 
Chloral  as  sedative,  368 
Chloretone,  454 
Chloroform  for  rehef  of  pain,  216 


576 


INDEX 


Chlorosis,  Egyptian,  loi 
in  girls,  386 

hyperchlorhydria  in,  475 
Cholelithiasis,  76 

radio-diagnosis  of,  146 

search  for  stone  in,  76 

Cholera  nostras,  108,  278,  403 

simulated  by  trichiniasis,  563 
spirilla,  107 
Cholesterin  in  feces,  75 
Chronic  diarrhea,  522 
Circumference  shadow,  139 
Cirrhosis  of  liver,  achylia  in,  424 
Climacteric,  diarrhea  after,  519 
Climate,    change   of,   benefits   from, 
542 
for  diarrhea,  523 
"Climate  of  the  mind,"  3 
Cocain  as  gastric  sedative,  367 
Coccidium  in  intestines,  557 
Cocoa  butter  inunctions,  349 
Cohnheim's  oil  treatment,  454 
Cold,  application  of,  in  achylia  gas- 
trica,  271 
with  electricity,  214 
enema,  psychic  effect  of,  270 
-mitten  friction,  269,  279 
percussion,  271 
Coley's  fluid,  479 
Colic,  enemas  for,  247 
gall-stone,  76 

in  spastic  constipation,  548 
intestinal,  9 
mucous,  73,  78,  397 
recurrent  attacks  of,  512 
Colitis,  catarrhal,  397,  398 
membranous,  243 
muco-membranous,  278 
ulcerative,  242 
Collapse,  saline  infusions  in,  349 
Colliquative  diarrhea,  519 
Colloid  carcinoma,  462 
Colon,  ascending,  obstruction  of,  36 
palpation  of,  36 
enormous  flushing  of,  249 
impacted,  causing  pain  in  back, 

40 
irrigation  of,  255 
motility  of,  152 
needle  douche,  258 
pathologic  states  of,  157 
percussion  of,  18 
position  of,  152 
radiograph  of,  157 
rectal  injection  of,  149 
transverse,  sacculation  and  per- 
istalsis of,  33 
tube,  introduction  of,  253 
recurrent,  254 
use  of,  157 


Colon,  vibration  of,  212 

V-shaped  ptosis  of,  544 
Colonic  massage  bags,  258 

ulcers,  494 
Coloptosia,  complete,  153 
Coloptosis,  147 
Color  gradations,  52 
"Color  sense,"  physician's,  50 
Coma  from  checking  diarrhea,  518 
Compensatory  diarrhea,  517 
chronicity  of,  522 
in  old  people,  518 
in  uremia,  519 

hemorrhage  in  drunkards,  457 
"Complainers,"  chronic,  4 
Complement  deviation,  471 
Compress,  revulsive,  270,  271 

spongiopiline,  272 
Compresses,  hot,  for  nausea,  268 
in  acute  gastritis,  270 

ice  water,  269 
Concretions,  intestinal,  352 
from  magnesia,  352 

of  medicines,  78 
Condurango  in  cancer,  478 
Congenital  dilatation  of  colon,  33 

of  stomach,  431 

pyloric      stenosis,       orthopedic 
treatment  of,  432 
Connective  tissue  in  stools,  73 
Constipation,  543 

agar  agar  in,  552 

as  a  cause  of  colic,  9 
of  mucous  colic,  397 

as  a  pathologic  symptom,  543 

atonic,  218,  274,  547,  548 

calomel  in,  554 

causes  of,  544,  547,  548 

chronic,  treatment  of,  214 

copious  water-drinking  for,  264 

counter-irritation  for,  274 

cured  without  drugs,  297 

drug  therapy  in,  553 

emancipation  from,  556 

enemas  for,  247,  251 

from  irregular  habits,  543 

from  obstruction,  544 

habitual,  549 

in  small  eaters,  312 

in  young  girls,  295 

long-standing,  274 

marked,  168 

massage    and    gymnastics    for, 
550 

mineral  waters  for,  423 

neuromuscular  causes  of,  546 

obstructive,  547,  549 
full  diet  in,  555 

petroleum  in,  555 

prognosis  in,  549 


INDEX 


577 


Constipation,  reflex  causes  of,  546 
relieved  by  Rose  belt,  232 
spastic,  273,  274,  545,  547,  548 

prevention  of,  552 
surgery  for,  274 
treatment  of,  550 

by  hydrotherapy,  273 
with  hyperacidity,  353 
Conversation,   troublous,   avoidance 

.  of,  445 
Copremia,  298 
Corrosive  poisoning,  408 
Corset,  fitting  of,  227 
for  gastroptosis,  225 
like   perfectly   fitting   garment, 

227 
straight-front,  223,  226 
Cotton-seed   oil    enemas,    252,   275, 

507 
for  constipation,  551,  552 
Council  on  Pharmacy  and  Chemistry 
of   the   American    Medical 
Association,  337 
Counter-irritation  from  iodine,   218 
indications  for,  215 
-pressure,  224 
Cramps,  abdominal,  168,  398 

epigastric,  388 
Creatin  in  urine,  265 
Croton  oil  as  drastic,  362 
Crying,  tendency  to,  1 1 
Cysts  from  echinococci,  92 
in  stomach,  464 
pancreatic,  34 
trichinous,  95 

D 

Dairy  products,  chemic  composition 

of,  326 
Death,    sudden,  in  duodenal  ulcer, 

489,490 
Debauch,  alcoholic,  268,  423 
Decubital  ulcer,  492 
Defecation,  habit  of,  295 

in  early  morning,  296 

painful,  275,  549 

psychic  management  of,  297 

regular  time  for,  296 
Deformity  of  pylorus,  135 
Deglutition,  impediment  to,  6 

in  cardiospasm,  382 

sounds,  22 
Dehio's  investigations,  18,  20 

method  of  outlining  stomach,  31 
Delay  in  instituting  treatment,  306 
Delirium  tremens,  424 
Demulcents  in  corrosive  poisoning, 

408 
Depression,  mental,  in  dyspeptics,  2 

Z7 


Dermatitis  from  adhesive  plaster,  228 
Desquamative  catarrh,  74 
Dextrose,  58 

Diagnosis  based  on  subjective  symp- 
toms, 10 

by  means  of  X-ray,  no 

by  microscopic  examination,  15 

methods  of,  15 

of  digestive  diseases,  376 

positive,  advice  following,  160 
Diaper,  infection  from,  497 
Diarrhea  as  a  pure  neurosis,  396 

at  new  moon,  294 

cathartica,  516 

caused  by  lactose,  341 

chronic,  413,  521 

sanatorium  treatment  of,  523 

definition  of,  515 

drug  treatment  of,  524 

dyspeptica,  516 

entozoica,  517 

excessive,    saline    infusions    in, 

349 

explosive,  278 

following  extensive  burns,   519 

from  increased  peristalsis,  515 

from  irritating   substances,   516 
in  the  blood,  517 

from  toxic  state  of  blood,  518 

frothy,  353 

gastrica,  517 

gastrogenic,  416 

if  no  access  to  toilet,  520 

in  cancer,  480 

in  pellagra,  72,  518 

nervosa,  382,  519 

stercoralis,  517 

suspicious,  108 
Diastase,  359 
Diet  bland,  333 

bulky,  512 

considerations  of,  315 

faddists  in,  320 

for  constipation,  550 

ideal,  317 

in  diarrhea,  523 

in  digestive  disorders,  329 

in  dysentery,   530  _ 

in  hyperchlorhydria,  392 

in     hypersecretion     of     gastric 
juice,  332 

in  rest  cure,  311 

liberal,  benefits  from,  350 

in  proctitis,  497 

psychotherapy  in,  307 

rational  and  sustaining,  350 

scheme,  graduated,  291 

too  restricted,  330 
Dietary,  appetizing,  323,  332 

cutting-down  of,  289 


578 


INDEX 


Dietary  for  the  sick,  322 
standards,  319,  321 
Dietetic  errors,  410 

fears,  how  created,  289 
indiscretions,  9 
Dieting,  foolish  systems  of,  11 
Digestants,  358 

Digestion  affected  by  ill-temper,  293 
effect  of  emotions  on,    282 
influence  of  mind  upon,  284 
psychoneurosis  of,  314 
Digestive  diseases,  causing  continu- 
ous distress,  5 
classification  of,  5 
diagnosis  of,  i,  15 
drug  therapy  in,  351 
in  persons  of  refinement,  4 
in  the  business  man,  4 
in  the  old,  378 
in  the  young,  3 
prenatal  causes  of,  5 
juices,  working  quantity  of,  307 
neuroses,  377 

psychotherapy  in,  402 
therapy  of,  400 
Digestives,  use  of  term,  370 
Dilatation  for  cardiospasm,  383 

gastric,  passage  of  stomach-tube 

in,  437 
of  pylorus,  129 
of  stomach,   163,   186,  426, 
489 
acute,  435 _ 

prognosis  in,  437 
atonic,  15 
chronic,  429 
diagnosis  of,  436 
post- operative,  435 
treatment  of,  272 
"Dirt  eaters,"  loi 
Discomfort,  intestinal,  5,  8 
Discontent  as  cause  of  indigestion, 

?93 
Disinfection  of  gastric  mucosa,  204 
Disproportion    between    pulse    and 

temperature,  165 
"Distempers,"'  ancient,  287 
Distention  of  colon  by  air,  152 
Distomiasis,  97,  561.     See  also  Fluke 

Worms. 
Distomum  lanceolatum,  100 
Diverticulum  of  esophagus,  27,  11 1 

of  stomach,  124 
Dog  meat  a  cause  of  nausea,  286 

as  food,  285,  287 
Dogs,  tasnia  echinococcus,  in  92 
Dorsal  pain,  442 
Douche,  alternate,  268 

cold,  in  constipation,  273 
fan  and  jet,  272 


Douglas'  cul-de-sac,  worms  in,  88 
Dragging-down  sensation,  222 
Drigalski-Conradi  plate,  106 
"Dripping  sounds,"  23 
Drug  habit,  formation  of,  379,  384 

therapy,  351  _ 
Drunkards,  gastric  erosions  in,  457 
Duodenal  alimentation,     343,     446, 

455 
conditions    in    which    useful, 

344 
bucket,  383,  430 
cap,  160 

obliteration  of,  161 
contents,  characteristics  of,     67 

examination  of,  63,  66 
feeding  apparatus,  340,  341 

at  blood  temperature,  341 

technic  of,  342 
ileus,  435 
juices,  methods  of  obtaining,  63 

microscopic  examination  of,  67 
self-feeding,  341 
syringe,  341 
test-meal,  64 
tube,  clogging  of,  343 

Gross,  245 

obstacles  to  passage  of,  66 
ulcer  due  to  burns,  485 

hemorrhage  from,  489 

operation  for,  485,  492 

perforation  of,  490 

relapses  in,  487 

surgery  in,  492 

symptoms  of,  130,  152 

tenderness  of,  32 

treatment  of,  280,  491 
surgical,  166 

"tucked  back,"  486 

X-ray  therapy  in,  211 
Duodenum,  acid  reaction  in,  245 
aspiration  of,  64,  342 
kinking  of,  162 

treatment  for,  162 
lavage  of,  244 

contraindicated,  246 
stenosis  of,  151 
torsion  of,  16 
tumors  of,  34 
V-shaped,  545 
Duration  of  digestive  diseases,  5 
Dysentery,  acute,  hydrotherapy  in, 
277 
amebic,  79,  526 

clinical  picture  of,  534 
among  orang-outangs,  558 
as  an  infectious  disease,  525 
bacillary,  108,  526 
careful  management  of,  528 
catharsis  in,  531 


INDEX 


579 


Dysentery,  chronic,  278 
irrigation  in,  532 

complications  of,  528 

diphtheritic,  527 

follicular  form,  528 

in  Manila,  82 

in  warfare,  525,  526 

nursing  in,  528 

pain  in,  532 

source  of  infection  in,  527 

sporadic,  526 

water-borne,  533 
Dyspepsia,  amylaceous,  359 

functional,  7 

gastric  analysis  in,  413 
"Dyspeptic  environment,"  5 
Dyspeptics,  concessions  to,  309 

mental  state  of,  2,  13 

E 

Eating,  excessive,  307,  385,  426. 

See  also  Bulimia. 
Echinococcus  disease,  93 
Ectasia  ventriculi,  429 
Eggs  as  irritant  food,  287 
in  cancer  dietary,  477 
per  rectum,  348 
Einhorn's  diet  in  gastritis,  420 
duodenal  alimentation,  446 
method  in  gastric  ulcer,  455 
pump,  65 
tube,  341 
esophageal  bougie,  207 
method    of    aspirating    duode- 
num, 65 
powder-blower,  204,  459 
test  for  acetic  acid,  55 
Electric  cabinet,  274 
compress,  274 
current,  power  of,  207 
head-light,  241 
illumination,    examination    by, 

23,  24 

pad,  272,  450 

transiUumination,  13 
Electricity,     abdominal     conditions 
benefited  by,  209 

diffusion  of,  209 

for  atonic  constipation,  551 

in  digestive  neuroses,  401 

in  rectal  examination,  236 

intragastric,  use  of,  205,  208 

percutaneous,  208 

psychic  effect  of,  419 

static,  209 
Electrode,  epigastric,  208 

intragastric,  207 
Electro-magnet  passed  into  stomach, 

483 
-therapy  in  chronic  cases,  209 


Electrovibrator,  213 

Emaciation  as  a  symptom,  145,  412 

butter  in  dietary  for,  341 

diet  in,  330 
Emesis  as  auto-lavage,  365 
Emetin  hydrochlorid  in  dysentery, 

538,  540 
Emollient  enemas,  251 
Emotion,  inhibitory  effect  of,  6 
Emphysema,  pulmonary,  171 
Emptiness,  sensation  of,  304 
End  reaction,  51 
Enema  in  sitting  position,  254 

obstruction  to,  255 
Enemos     at     "hydrant     pressure," 
248 

daily,  271 

for  various  conditions,  247 

in  gastritis,  270 

methods  of  giving,  248 

nutritive,  248,  345,  346 
indications,  for  347 

of  enormous  quantity,  249 

oil,  251,  252,  275 

saline,  high,  346 

temperature  of,  250 
Energy,  furnishing  of,  317 
Entameba  coli,  81,  82 

in  pellagrin  stools,  536 
histolytica,  82,  536 
Enteritis,  gravel-forming,  78 
Enteroclysis,  186 
Enterocolitis,  275 
Enteroliths,  77 
Enteroptosis,  belt  for,  232 

in  the  slender,  228 

in  women,  545 

treatment  of,  271 
Enteroptotic  habitus,  378 
Environment,   change  of,   309,    356, 

402,  423 
Environment,  cheerful,  310 
Enzymes,  effects  of  electricity 'upon, 

205 
Epidemics  of  dysentery,  prevention 

of,  526 
Epigastralgia,  214,  377 

relief  of,  216 
Epigastric  compres.ses,  272 

pain,  389,  441 

pressure,  significance  of,  8 
Epigastrium,  counter-irritation  over, 

215 

flattening  of,  437 

mass  of  tumors  in,  34 

palpation  of,  29 

tenderness  in,  31 
Epiglottis,  irritable,  199 

sensitiveness  of,  172 
Epithelial  cells  in  stools,  74 


58o 


INDEX 


Erosions  of  gastric  mucosa,  172 

of   stomach,   treatment   of,  458 

rectal,  496 
Eructations,  explosive,  303,  384 

in  chronic  catarrh,  411 
Erythema  of  hands  in  pellagra,  10 
Erythrodextrin,  58 
Escharotics,  use  of,  244 
Esculin,  43 
Eserin  in  acute  dilatation,  438 

laxative  effect  of,  360 
Esophageal  bougie,  divisible,  207 

dilatation  by  silk  thread  method, 
28 

diseases,  electrical  treatment  of, 
210 
with  malignant  tendency,  210 

electrode,  27 

sound,  26 

stricture  from  ingestion  of  acid, 
28 

walls,  outline  of,  iii,  112 
Esophagismus,  210 
Esophagoscope,  use  of,  23,  25 
Esophagoscopy    in    cancer    of    the 

cardia,  468 
Esophagus,  cancer  of,  iii 

cicatricial  stenosis  of,  210 

disease  of,  6,  7 

diverticulum  of,  7 

length  of,  179 

malignant  growths  in,  29 

passage  of  food  down,  334 

plugging  of.  III 

rapid  emptying  of,  1 1 1 

sacculation  in,  1 1 1 

secretion  of,  26 

stenosis  of,  7 

stricture  of,  22,  27,  113 
impermeable,  28 

worms  in,  561 

X-ray  examination  of,  no 
Ethereal  sulphate  output,  266 
Evacuation  of  bowels,  299 

of  food  from  stomach,  330,  427 
Evacuations    in    amebic    dysentery, 

534 
Ewald-Boas  test-meal,    45,    48,    61, 

442,  488 
Ewald  s  diet  for  chronic  gastritis,  420 
test-meal,  45 
treatment  of  ulcer,  447 
Examination  of  patients,  10 
Exploratory   operation,    advantages 

of,  168 
"Expression  method,"  180 
Extremities,  cold,  relief  of,  277 

massage  of,  277 
Exudate,  sero-mucous,  501 
Eye-strain,  386 


P 


Facial  expression,  30 

Faintness  from  coal-tar  drugs,  369 

from  invisible  hemorrhage,  489 
Fan  douche,  272,  277 
Faradic  current  in  cases   of  atony, 
206 

value  of,  205 
Fasciola  hepatica,  100 
Fasciolopsis  buski,  97,  100 
Fasting  stomach,  contents  of,  63 
Fat  digestion,  impaired,  246 

in  abdomen,  231 

in  mushes  and  soups,  328 

in  stools,  73 
Fats   a   cause   of   food  retention  in 
stomach,  330 

emulsified,  359 

in  food,  316 

in  hyperchlorhydria,  393 

retention  of,  in  stomach,  262 
Fauces,  sensitiveness  of,  172,  175 
Fear,  cathartic  effect  of,  285 
Febrile   conditions   and  use   of   the 

stomach-pump,  172 
Fecal  accumulation,  21,  551 

current,  acceleration  of,  12 

movement,    varying    habit    in, 
299 

nitrogen,  decrease  of,  265 
Feces,  ameba  dysenteriae  in,  80,  527 

analyses  of,  in  ulcer,  446 

ball-shaped,  545 

blood  in,  489 

burying  of,  568 

concretions  in,  77 

constituents  of,  75 

contamination  of  soil  with,  568 

examination  of,  69 
macroscopic,  72 

gall-stones  in,  76 

hookworm  eggs  in,  102 

investigation  of,  108 

larvse  of  flies  in,  103 

nematode  in,  95 

normal  characteristics  of,  69,  72, 

occult  blood  m,  59 

sources  of,  62 
parasites  in,  74,  75,  84,  85,  543 
segments  of   tapeworm  in,  561 
tarry,  489 

tumor  fragments  in,  79 
Feeding,  duodenal,  446 

intolerance  of,  344 
of  delirious,  comatose,  or  insane, 

348 
Feldspar,  poultice  of,  216 
Fermentation,  delayed,  186 


INDEX 


581 


Ferments,  artificial,  359 
Fibromata  of  stomach,  464 
Fibromyomata  of  stomach,  464 
Filmaron  for  tapeworm,  560 
Fingerprints,  nodules  similar  to,  474 
Fish,  chemic  composition  of,  325 

raw,  eating  of,  92 
Fissure  of  anus,  235,  275,  276,  507 
Fistula    following    local    peritonitis, 
491 

rectal,  detection  of,  235 
Flabby  abdomen,  223,  381 

support  of,  222 

stomach,  209 
Flatulence,  drug  therapy  of,  354 

due  to  swallowed  air,  364 

from  milk  diet,  530 

intestinal,  300 

in  the  neurotic,  303 

painful,  355 

relief  of,  254,  271,  363,  364 
Flatus,  accumulation  of,  220 

during  irrigation,  258 
Fleiner's  and  Aaron's  method,  453 
Flesh,  loss  of,  389 
Fletcherism,  335,  336 
"Flicking  percussion,"  20 
Flies,  larvse  of,  in  stools,  103 
Fluids  with  meals,  260 
Fluke  worm,  97,  561 

infection,  symptoms  of,  98,  561 
treatment  in,  561 
Fluorescent  media,  42 
Fluorescin,  43 
Fluoroscope,  use  of,  1 1 1 
Fluoroscopic  examination,  22,  23 

inspection  in  the  cat,  293 
Fly  in  food  a  cause  of  nausea,  285 
Fomentations,  hot,  270,  271,  273 
Food,  abstinence  from,  in  gastritis, 

405 
albuminous,  448 
aversion  for,  386 
caloric  value  of,  318 
classification,  315 
customs  of  mankind,  320 
evacuation  of,  from  stomach, 

331 

-fear  as  result  of  dyspepsia,  2 
fried,  392 

ingestion  of,  followed  by  pres- 
sure, 8 
liberal  intake  of,  393 
personal  idiosyncrasies  to,  319 
poisonings,  516 
questions,  319 
regurgitation  of,  276 
requirement,  at  rest,  318 

in  health,  317 
residue,  diet  leaving  little,  329 


Food,  residue,  irritating,  555 
large,  550 
small,  a  cause  of  constipation, 

.547 
stimulating  action  of,  312 
retained  in    stomach    nineteen 

hours,  127 
scratchy  articles  of,  452 
stagnation,  379 
-stasis,  470 
sterilization  of,  538 
stratification  in  stomach,  262 
substances,  chemic  composition 

of,  324 
suppositories,  349 
undigested,  acting  as    a  foreign 
body,  329 
Foods,  artificial,  336 

proprietary    and    patented,  336 
without  secretagogues,  283 
Foodstuffs,     mental     attitude     con- 
cerning, 286 
Foot  bath,  hot,  for  nausea,  268 
Foreign  bodies  in  stomach,  146,  460, 
481 
1446  found, 482 
psychic  influence  of,  484 
treatment  of,  483 
X-ray    diagnosis    of,    482, 
484 
Foreign  body,  duodenal  tube   acting 
as,  344 
removal  of,  26 
Fountain  syringe  for  enemas,  248 

"Niagara,"  254 
French  army  officer  with  abnormal 

bowel,  299 
Friedlieb  apparatus,  190,  193 
Friedenwald's  diet  in  gastritis,  421 
Fruits,  chemic  composition  of,  327 
Furuncles     from     adhesive    plaster 
bandage,  229 

G 

Gall-bladder    adherent    to   pylorus, 

135 

disease       differentiated       from 
hyperacidity,  389 
painful  area  in,  40 
with  achylia,  474 
tenderness,  404 
Gall-sand,  77 
Gall-stones,  analysis  of,  77 

concretions  resembling,  77 
in  feces,  76 
search  for,  76 
size  of,  76 
Galvanic  current,  sedative  effect  of, 

205 
Galvanization,  intragastric,  458 


S82 


INDEX 


Game,  chemic  composition  of,  325 
Gangrene  from  worm  in  trachea,  562 
indications  of,  164 
of  appendix,  164 
of  intestines,  536 
Gant's  speculum,  240 
Gas-bubble  in  stomach,  139 
Gas,  eructations  of,  200 

liters  of,  301 
Gaseous  eructations,  relief  of,  479 
Gasterin  as  digestant,  357 
Gastralgia,  377,  384 

treatment  of,  204 
Gastrectasis,  426 
acute,  435 

diflFerentiated  from  aerophagia, 
301 
Gastric  acidity,  bicarbonate  of  soda 
in,  351 
analysis,  412 

cancer,  macroscopic  and  micro- 
scopic examination  in,  470 
mechanic  treatment  of,  478 
medical    treatment    of,    477, 

478 
symptoms  of,  465 
subjective,  469 
tests  for,  470 
carcinoma  and  sarcoma  differ- 
entiated, 463 
catarrh,  245 

treatment  of,  279 
contents,  analyses  of,  in  ulcer, 
446 
churning  of,  261 
evacuation  of,  262 
crises,  8,  9 

digestion,  stimulation  of,  283 
dilatation,  15,  16 
distress  relieved  by  corset,  225 
examination,    preparations   for, 

16 
evacuation,  117 
filtrate,  51 
flatulence,  300 
hemorrhage,  causes  of,  439 
prognosis   and   treatment  of, 
440 
intoxication,  acute,  407 
irritability,  446 
juice,  deficiency  in,  324 
digestants  made  from,  357 
dilution  of,  261 
excessive,  394 

flow  of,  on  sham  feeding,   293 
lavage,  apparatus  for,  188,  193 
astringent,  369 
benefits  of,  186 
dangers  in,  202 
for  hyperchlorhydria,  391 


Gastric  lavage,  frequency  of,  201 
hot  and  cold,  269 
indications  for,  185,  199 
Leube-Rosenthal  method,  188, 

189 
possible  accidents  in,  190 
toleration  of,  194 
when  harmful,  401 
with  medicaments,    190,   199 
with  nitrate  of  silver,  270 
mucosa,  damage  to,  174 
disinfection  of,  204 
drugs  irritating  to,  367 
erosions    of,    172,    200,    414, 

457. 
infection  of,  409 
intolerant  of  acid,  356 
irritable,  200 
perforation  of,  185 
pus  in,  408 

sensitiveness  of,  387,  401 
sloughing  of,  407 
mucus,  excessive  quantities  of, 

413 

lavage  for,  270 
significance  of,  63 

neroseus  and  eye-strain,  386 
therapeutic  tests  in,  368,  380 

phlegmon,  25,  408,  409 

residue,  fermentation  of,  201 

sarcoma,  primary,  462 

secretion,  deficient,  333 
inhibition  of,  392 

sedatives,  367 

sensation,  abnormal,  205 

serosa,  peritonitis  of,  436 

shadow,  123,  124 

spray,  203 

tetany  with  ulcer,  456 

tumors,  location  of,  469 
size  of,  468 

ulcer,  124,  440.     See  also  Ulcer 
of  Stomach. 
chronic  non-indurated,  125 
concentrated  foods  in,  448 
diet  in,  333,  446,  447 
differentiated  from  catarrhal 

gastritis,  415 
excision  of,  457 
healing,  140 
hot  applications  in,  450 
hydrotherapy  in,  280 
Lenhartz  treatment  of,  446 
mortality  from,  449 
mouth  feeding  in,  451 
penetrating,  139 
pressure  point  in,  441 
reaction  dilatation  in,  454 
skiagram  of,  139 
spontaneous  cure  of,  455 


INDEX 


583 


Gastric  ulcer,  tenderness  of,  32 
test  for,  367 
treatment  of,  445 
contraindicated,  205 
surgical,  166 
von  Leube's,  446 
X-ray,  211 
wall,  paralytic  relaxation  of,  436 
Gastritis,  acute,  270,  403 

and    chronic,     differentiated, 

404,  415 
diet  in,  405 
infectious,  406 

drug  therapy  in,  407 
interstitial,  408 
treatment  of,  404 
alcoholic,  411,  423 
border-line  cases  of,  417 
catarrhal,  treated  by  gyromele, 

215 

chronic,  186,  270,  403,  415 
catarrhal,  410 
diet  in,  420,  421 
treatment  of,  417 
by  lavage,  201 
by  medicines,  422 
with  erosions,  458 
polypoid,  461 
phlegmonous,  25,  408,  409 
sub-acid,  411,  414,  428 
toxic,  403,  407 
Gastrodiaphany,  41,  42 
Gastrodynia,  384 
Gastroenterostomy,  123,  492 
Gastrogenic  diarrhea,  517 
Gastrointestinal  diseases,  electricity 
in,  208 
essential  treatment  of,  306 
failure  of  radium  in,  212 
hydrotherapy  in,  260 
psychotherapy  in,  282 
Gastronomic  excesses,  426 
Gastroptosi  with  hypermotility,  133 
Gastroptosis,  16 
contours  in,  44 
corset  for,  225 
diagnosis  of,  17,  19 
in  the  slender,  228 
mistaken  for  dilatation,  429 
treatment  of,  271 
with  movable  kidney,  226 
Gastroscope,  use  of,  26,  484 
Gastroscopy,  24,  26,  469 
Gastrosuccorrhea,_393 

morning  vomiting  in,  9 
organic  cause  of,  394 
vomitus  in,  394 
Gastrotomy,  28 
Gelatin  in  hematemesis,  369 
in  hyperchlorhydria,  393 


Germain-S6e's  test-meal,  45 
Germicide  solutions,  541 
Girdle,  cold  wet,  271 

Neptune's,  269,  273,  276 
Glands,  lymphatic,  enlargement  of, 

Glandular  activity,   stimulation  of, 

422 
Globus  hystericus,  7 
Glycerin  suppositories,  297,  552 
Glycyl-tryptophan  test,  471 
GmeUn's  test  in  gall-stones,  77 
Gonorrhea  as  cause  of  rectal  ulcer, 

Greater    curvature,    infiltration    ot, 
160 

jagged  and  irregular,  161 

transverse  constriction  of,  129 
Grief  as  cause  of  indigestion,  285 
Griping,  excessive,  relief  of,  532 

from  cathartics,  556 

in  abdomen,  396 
Gross  duodenal  tube,  64 
Ground-itch,  564,  567 

anemia,    564.     See   also   Hook- 
worm Disease. 
Growths  in  epigastrium,  33 

in  right  ihac  fossa,  38 
inguinal  region,  38 

in  umbilical  region,  37 
Guaiac  test  for  blood,  60 
Gummatous  masses  in  stomach,  475 
Gunsburg's  phloroglucin-vaniUm 

test,  49 
Gurgling  sounds,  381 
Gymnastics    for    constipation,    219, 

550 

Gyromele,  214,  215 

H 

"  Haakenworm,"  lOi 
Habit  formation,  295 
Habitues,  alcoholic,  425 

morphin,  474 
"Habitus  enteropticus,"  12 
Hairball  in  the  stomach,  146,  482 
Hair  follicles,  infection  in,  229 
Hair-pin    removed    from    stomach. 

Hairs  of  plants  m  feces,  505 
swallowing  of,  481,  482 
Ham,  raw,  trichina  in,  563 
Hand  vibrators,  212 
Hare  enema,  251 
Head  injuries   as   cause   of   gastric 

dilatation,  436 
"Head  zones,"  39 
Health  resort,  sojourn  at,  355 
Heart-burn,  355,  441 


584 


INDEX 


Heart-disease,  organic,  171 

with    broken    compensation, 
171 
shadows,  113 
Heat  combined  with  electricity,  214 
for  relief  of  pain,  217 
generation  of,  317 
units  in  food,  324 
Helminthiform  masses,  152 
Hematemesis,  34,  439,  442 
astringents  for,  369 
gelatin  for,  369 
in  gastric  ulcer,  415 
into  intestine,  145 
Hematin,  extraction  of,  59 
Hemorrhage  checked  by  enemas,  247 
from  duodenal  ulcer,  489 
from  intestinal  ulcer,  494 
from  stomach,    145,    167,    439, 
442 
treatment  of,  280 
surgical,  167 
gastric,  caused  by  foreign  body, 

482 
in  gastric  ulcer,  466 
recent,  and  the  stomach-pump, 
171 
Hemorrhoids,  347,  498,  507 

detection  of,  235 
Hepatic  flexure,  displacement  of,  547 
Hepatin  as  digestant,  357 
Heredity  a  cause  of  rumination,  384 

of  cancer,  460 
Hernia,  epigastric,  464 
Hiccough  in  dilatation  of  stomach, 
436 
treatment  of,  272 
High  irrigation,  255 
Hirschsprung's  disease,  33 
History,  elicitation  of,  41 
Hodgkin's  disease,  35 
Hog  parasite,  82,  85 

trichiniasis  in,  93 
Holadin  and  bile  salts,  365 
Honey  as  bowel  stimulant,  297 
Hookworm,  100,  564 

detection  of  eggs  of,  102,  565 
disease,  loi,  564 

as  sociologic  problem,  565 
diagnosis  of,  565 
forms  of,  564 
origin  of,  564 
prophylaxis  of,  567 
symptoms  of,  566 
treatment  of,  568 
ova,    microscopic    examination 
for,  565 
Hormonal,  360 
Hormones,  11,  283 
influence  of,  324 


Horn-shaped  stomach,  474 
Hot-air  cabinet,  274 
Hot  applications  in  gastritis,  405 
in  hyperchlorhydria,  271 

water  bag  for  relief  of  pain,  217 
coil,  274 
sipping  of,  271 
Hour-glass  stomach,  140,  141 

symptoms  of,  140,  145 
Hunger,  abnormal  sense  of,  385 

constant,  from  self-dieting,  290 

pain,  486 
Hydragogue  cathartics,  363 
"Hydrant    pressure"    in    irrigating 

bowel,  248 
Hydrochloric  acid,  356 

absence  of, ingastric  tumors,  470 

free,  computation  of,  52 

tests  for,  49 

in  60-drop  doses,  422 

in  stomach  contents,  47 
Hydrostatic  pressure  of  enemas,  248 
Hydrotherapy,  260 

first  principle  of,  267 

for  constipation,  273 

for  peristaltic  unrest,  381 

in  antiquity,  260 

in  cholera  nostras,  278 

in  constipation,  551 

in  enteroptosis,  271 

in  gastralgia,  385 

in  gastric  ulcer,  280 

in  gastritis,  270 

in  gastroptosis,  271 

in  hyperchlorhydria,  271 

in  nervous  dyspepsia,  277 

in  pyloric  stenosis,  433 

investigation  of,  281 
Hygiama,  447 
Hygiene,  value  of,  351 
Hyperacidity  of  stomach,  118,  124 

diagnosis  of,  388 

variations  in,  388 

with  constipation,  treatment  of, 
200 
Hyperalgesic  areas,  39 
Hyperchlorhydria,  8,  9,  51,  271 

as  duodenal  ulcer,  489 

as  secretory  neurosis,  387 

burning  qructations  in,  301 

diet  in,  332,  392 

nervous,  379 

pain  due  to,  353 

treatment  of,  271,  390 
Hyperesthesia,  gastrica,  367,  385 

of  abdomen,22 

over  epigastrium,  384 
Hyperkoria,  386,  465 
Hypermotility  of  stomach,  117,  130 

as  a  symptom,  152 


INDEX 


585 


Hyperorexia,  385 
Hyperpepsinia,  56 
Hypersecretion,  378 

alimentary,  395 

symptom  of,  413 
Hypnotics  in  digestive  diseases,  368 

influence  of,  368 
Hypochlorhydria,      271.     See     also 

Achylia  Gastrica. ' 
Hypochondriac   region,    left,    exam- 
ination of,  35 
Hypopepsinia,  56 
Hypotony  of  stomach,  426 
Hysteria  in  digestive  diseases,  8 
Hysteric  patient,  tactful  treatment 
of,  30 


I 


Ice-bag  in  gastric   hemorrhage,  440 
to  epigastrium  for  hiccough,  272 
Ice-cold  water,  ingestion  of,  263 
Ice  for  relief  of  nausea,  268 

use  of,  in  cholera  nostras,  278 
-water  lavage,  187 
Iced  feeding  spoon,  448 
Icterus,  treatment  of,  246 
Idiosyncrasy  against  bismuth,  454 
against  milk,  530 
against  stomach- tube,  172 
concerning  food,  287 
Ileocecal  intussusception,  37 
Imitation   as   cause   of   rumination, 

384 
Inanition,  162 
Indefinite  ills,  167 
Indican  in  urine,  266,  267 
Indicanuria  in  pyloric  stenosis,  431 
Indigestion,  chronic,  i,  410 

fear  of,  289,  290 

forms  of,  377 

nervous,  378 

psychic,  lasting  8  years,  290 

suggestions  of,  289 
Infant  foods  as  compared  with  milk, 

.338 
Infants,  ileocolitis  of,  526 
Infectious  gastritis,  acute,  406 
Infiltration  of  stomach,  160 
Inflation  of  stomach,  13 

value  of,  in  gastric  cancer,  468 
Inguinal  fossa,  left,  growths  in,  39 

region,  left,  growths  in,  39 
Injections  for  constipation,  551 
Injuries    from    swallowed    articles, 

.439 
Inorganic  salts  in  food,  316 
Insalivation,  335 
Insomnia,  relief  of,  368 
with  indigestion,  308 


Inspection  of  abdomen,  16 

in  gastric  cancer,  467 

Interstitial  gastritis,  acute,  408 

Intestinal  antiseptics,  364,  365 

autointoxication,  298 

fear  of,  300 
digestion,  aid  to,  360 
growths,  malignant,  160 
indigestion,  213 
juices  in  the  stomach,  62 
motility,     influence     of     mind 

upon,  294 
mucosa,  inflammation  of,  250 

irritated,  251 
neurasthenia,      diagnosis      and 

treatment  of,  396 
obstruction,  187 
parasites,  79,  557 
paresis,  post-operative,  186 
putrefaction     as     affected     by 

water- drinking,  266 
sand,  78 

in  mucous  colic,  397 
stasis,  547 

stenosis,  use  of  oils  in,  513 
strictures,  extensive,  514 
tuberculosis,  105 

stools  in,  105 
ulcer,  492 

diagnosis  of,  493 
diet  in,  494 
Intestine,  small,  outline  of,  152 
Intestines,    catarrhal   inflammation 
of,  546 
inflation  of,  13,  258 
life  of  hookworm  in,  103 
local  treatment  of,  233 
lubrication  of,  361 
peristaltic  unrest  of,  381 

waves  of,  17 
secretory  neuroses  of,  396 
stenosis  of,  511 

tetanic-like  contractions  of,  220 
tumor  of,  544 
twisted,  163 
Intravascular  feeding,  349 
Introspection,  habit  of,  209,  277 

morbid,  as  cause  of  indigestion, 
4,  310 
Intussusception,  187 
enemas  for,  248 
enteric,  37 
Inunctions,  nutrient,  349 
Invalids,  "experienced,"  167 

self-made,  289 
"Invigorators,"  445 
Iodine,  painting  with,  218 
Iodoform  reaction,  54 
Ipecac    as    specific    for    dysentery, 
539 


586 


INDEX 


Iron  tap  in  the  stomach,  146 

test  for  presence  of  blood,  61 
Irrigating  fluid,  250 

loss  ot  heat  in,  257 
preparation  of,  250 
temperature  of,  256,  257 

tube,  double  current,  255 
Irrigation,  cold,  270 

of  esophagus,  112 

intestinal,  solutions  for,  256 

of  duodenum,  244 

of  large  intestine,  253 

of  rectum,  496 
Irrigator,  varieties  of,  254 
Isochymia,  429 
Itching  from  adhesive  plaster,  228 

in  jaundice,  relief  of,  279 

in  rectum,  508 


Jackson's  method  of  gastroscopy,  24 

veil,  549 
Jamison's  irrigator,  254 

sitz-bath  pan.  511 
Jaundice  due  to  fluke  worms,  561 

from  malignant  disease,  34 

hydrotherapy  in,  279 

relief  of,  365 
Job's  cell-exhaustion,  282 


K 


Kamala  for  tapeworm,  560 
Kaolin  poultice,  216 
Kemp  belt,  230 

Kemp's  method  of  examination,  18' 
21 
of  irrigation,  257 
stomach  whistle,  21 
Kerosene  oil  for  worms,  563,  564 
injections    in     dysentery,    533, 
539.  540 
Kidney,  floating,  223,  224 
flushing  of,  246 
movable,  palpation  of,  31 

shape  and  consistency  of,  37 
suspended,  161 
Kidneys,  growths  in,  35 
Kilmer's  abdominal  belt,  223 
Kinks  in  intestines,  492,   513,   514, 

543,  546 
Kneading  of  abdomen,  221 

L 

Lab-ferment,  447 

Laborers,  day,  gastritis  among,  409 

Lactic  acid  in  gastric  cancer,  470 

in  the  diagnosis  of  cancer,  54 

tests  for,  45,  53 


Lactose  in  duodenal  feeding,  341 
Lane's  kink  and  coloptosis,  147 

influence  of,  in  constipation,  549 

of  ileum,  514 
Laparotomy,  exploratory,  167 
in  acute  dilatation,  438 

in  phlegmonous  gastritis,  409 
Larvae,  parasitic,  in  feces,  84 
Larynx,  spasmodic  closure  of,  172 

worms  in,  562 
Lavage  fluid,  temperature  of,  199 

frequency  of,  419 

habit,  202 

in  corrosive  poisoning,  408 

nutrition  lost  in,  433 

of  rectum  and  sigmoid,  74 

of  stomach,  145 

solutions  for,  419 

transduodenal,  244 

tube,  174,  187 
clogging  of,  194 
double  current,  188 
Laxative  drugs  as  cause  of  diarrhea, 

521 
Laxatives,  abuse  of,  275 

mildest,  360 
Lazy  disease,  568 

Lead-poisoning  as  cause   of   consti- 
pation, 546 
Leg  pack,  hot,  270,  277 
Lenhartz  diet  schedule,  449 
Leptodera  stercoralis  et  intestinalis, 

95 

Leube-Rosenthal  gastric  lavage,  189 
Leube-Ziemssen  method  of  feeding, 

455 
Leucocyte  counts,  164 
Leucocytosis,  absolute,  164 
Liniments  for  relief  of  pain,  218 
Lipomata  of  stomach,  464 
Liquid  diet,  indications  for,  332 
Liver,  abnormally  lobulated,  35,  36 

abscess,  535,  537,  542 
protozoa  in,  80 

diagnostic  puncture  of,  537 

fluke,  100,  561.     See  also  Fluke 
Worm. 

pain,  40 

prolapse  of,  475 

shadow,  133 
Lividity  caused  by  drugs,  369 
Lockwood  abdominal  belt,  224 

bulb,  180,  194 
Loose  bowels,  515 
Lubrication  of  tubes,  250 
Lumbar  region,  right,  examination 

of,  36 
Lunar  caustic,  application  of,  244 
Lymph  deposits  on  base  of  ulcer,  490 
Lymphosarcoma,  462 


INDEX 


587 


M 

Magnesia,  action  of,  352 

forming  concretions,  352 
Male  fern  for  tapeworm,  558,  560 
Malignancy   developing   after   mas- 
sage, 219 
Malignant  disease,  X-ray  therapy  in, 
210 

growths  in  stomach,  160 
late  and  early,  160 
Malnutrition,  312,  316 

dangerous  state  of,  330,  339 

tendency  to,  320 
Maltose,  58 

Manila,  dysentery  in,  82 
Massage,   abdominal,   contraindica- 
tions for,  219 

bags,  colonic,  258 

cannon  ball,  218 

electrovibratory,  213 

for  atonic  constipation,  550 

in  mucous  colic,  399 

movements  of,  220 

roller,  214 

vibratory,  212 
Mastication,  334 

hasty,  12 

interminable,  336 

temperamental,  335 
Maternal  blood,  472 
Mayo  clinic,  470 

cancer  records  in,  457 
Mayo's  reports  on  duodenal  ulcer, 

485 
Meals,  imbibing  fluids  with,  261 
Meat  broth,  lack  of  nourishment  in, 

339 

juices,  overrated  as  food,  338 

repugnance  to,  465 

tea,  dietetic  value  of,  339 
Meats,  chemic  composition  of,  325 
Mechano-therapeutics   in    constipa- 
tion, 274 
Medication,  demand  for,  373 

frequent  changes  in,  401 
Medinal,  effects  of,  368 
Medullary  carcinoma,  461 
Melena,  440,  442 
Membranous     enteritis,     396,    397. 

See  also  Mucous  Colic. 
Menstrual  irritation,  395 
Mental  attitude  in  rest  cure,  311 
of  patient,  2,  13 

depression  in  gastritis,  412 

disturbance  affecting  digestion, 
284 

storm,  388 
Merycism.     See  Rumination. 
Mesenteric  bands,  513 


Mesenteric    bands,   constriction    as 
cause  of  gastric  dilatation, 

435 
ileus,  435 
Metal  ball  in  intestine,  294 
Metastases,  220 
Meteorism,  364 

Methyl  salicylate  ointment,  218 
Methylene  blue  in  cancer,  479 
Microorganisms  in  stools,  104 
Microscopic  examination  of  stomach 

or  intestinal  contents,  15 
Migraine,  excessive  vomiting  in,  62 
Milk  diet  in  diarrhea,  523 
in  dysentery,  530 
with  carbohydrates,  328 

and  fat,  328 
with  solid  food,  pastry,  and 
broths,  329 
substitutes  for,  341 
Mine  anemia,  loi 

Mineral  springs,  benefit  from  sojourn 
at,  423       _ 
waters  in  gastritis,  422 
Mitchell,  Dr.  Weir,  311 
Mixed  diet,  advantages  of,  321 

food  loss  in,  322 
"Morning  sickness,  424 
Morphin   habitues,    bismuth   reten- 
tion in,  474 
in  gastritis,  405 
Motility,  loss  of,  129 
of  stomach,  427 
Motor  functions  of  intestinal  tract, 

293 

insufficiency,  186,  426 
alcohol  in,  428 
atonic,  430 
in  cancer,  470 
of  second  degree,  429,  430 

medication  in,  434 
stenotic,  430 
treatment  of;  428 
neuroses,  381 

power,  impairment  of,  186 
Mountain  anemia,  loi 
Mouse  in  cream  a  cause  of  nausea,285 
Mouth,  dryness  of,  529 
sepsis,  450 
watering  of,  283 
worms  in,  561 
Moving  equiUbrium,  state  of,  305 
Moynihan  on  duodenal  ulcer,  486 
Mucous  channels  in  rectum,  495, 498 
probing  of,  499,  503 
colic,  73,  78,  397 

treatment  of,  398 
colitis,  243,  397 

surgical  considerations  in,  400 
membrane,  peeling  of,  458 


INDEX 


Mucus,  absent  in  gastric  ulcer,  415 

cast,  397 

excessive,  in  stomach,  418 

gastric,  63 

in  dysenteric  stools,  534 

in  feces,  72,  494 

in  rectum,  241 

in  stomach,  186 
contents,  47 

sticky,  in  throat,  268 
Murphy  drop  method,  343,  450 
Muscles,  cysticerci  in,  90 

parasites  in,  88 

trichina  spiralis  in,  93,  563 
Muscular  rigidity,  165 
in  abdomen,  409 

tissue  in  feces,  73 
Musculature,  gastric,  tonicity  of,  302 
Mustard  plaster,  216 
Myasthenia,  426 
Myosarcoma,  462 
Myositis,  trichinous,  95 

N 

Naaman,    the    Syrian,    and    hydro- 
therapy, 260 
"Nachmagen,"  67 
Nature's  power  of  compensation,  300 
Nausea  caused  by  mental-  images, 
284 
by    nervous    or    mental    dis- 
turbance, 284 
by  thought  of  shambles,  284 
from  stomach- tube,  172 
of  gastritis,  404,  405 
relief  of,  268,  366 
tepid  water  for,  268 
with  flatulence,  relief  of,  355 
Nebuhzer,  258 
Necator  Americanus,  99,    100,  102, 

564 
Necrosis  in  intestines,  536 
Needle  douche,  258 
Negro,  hookworm  disease  in,  564 
Nephritis,  nausea  in,  268 

simulated  by  gastric  disease,  481 
Nephroptosis,  belt  for,  232 
Neptune's  girdle,  269,  273,  276 
Nerve  endings  in  abdomen,  206 
Nervous  anorexia,  relief  of,  268,  269 
debility,  tonic  for,  373 
diarrhea,  382,  396,  519 
dyspepsia,  33 

cured  in  four  weeks,  292 
static  electricity  in,  209 
treatment  of,  276 
indigestion,  diagnosis  of,  378 
relieved  by  change  of  board- 
ing place,  310 


Nervousness  as  cause  of  indigestion, 

3 

Nessler's  reagent,  54 
Neuralgia  of  stomach,  369,  384 

ovarian,  38 
Neuroses,  border-line,  394 

gastric,  8,  11,  206,  368 

intestinal,  78,  278,  303 

motor,  377 

secretory,  377,  387 

sensory,  377 
Neurotic  disturbance  of  digestion,  3 
Neurotics,  eliciting  of  history  from, 

Neutral  on,  391 

"New  thought"  cult,  289 

Nitrate  of  silver  for  erosions,  458, 

459 
in  gastric  ulcer,  452 
lavage,  199,  201,  391 

Nitric  acid  test  for  bile,  63 
Nitrogen  balance,  343 

income  and  outgo  of,  265 
Nocturnal  seizures,  476 
Nodular  indentations,  474 
Nodules,  malignant,  34 
Non-malignant  growths,  162 
Non-purgative    drugs    in    constipa- 
tion, 554 
Normal  stomach,  picture  of,  130 
Nourishment  of  body  as  a  symptom, 

10 
Nutrient  enemas  in  gastritis,  406 

recipes  for,  348 
Nutrition  below  par,  329 

disturbance  of,  213 

Fletcher's  work  on,  334 

in  the  body,  322 
Nuts,  chemical  composition  of,  327 


O 


Obese,  the,  examination  of,  16,  21, 31 
Obesity  as  impediment  to  diagnosis, 

Obsessions  of  dyspeptics,  12 
Obstruction,  cicatricial,  162 
Occult  blood,  442 

in  feces,  220,  489 

in  ulcer  of  the  stomach,  415 
Odor  of  feces  in  pellagra,  72 

of  stomach  contents,  47 
Oidium    albicans   in    the    stools    of 

children,  104 
Oil  enemas,  251 

in  mucous  colic,  398 

inunction,  349 
Oils  for  lubricating  intestines,  513 
Oily  hydrocarbons,  362 


INDEX 


589 


Olive  oil  enemas,  252 

for  inhibitory  effect,  392 

in  duodenal  ulcer,  491 
Omentum,  tumors  of,  33 
Onion,  prolonged  chewing  of,  336 

chewings  of,  336 
Open  air  exercise,  423 
Operation  in  malignant  infiltration, 

160 
Opium  as  astringent,  370 

habit,  532 

rectal  use  of,  347,  348 
Optimism,      sympathetic,      curative 

power  of,  305,  402 
Orang-outangs,     dysentery    among, 

•  558 
Orexin  as  appetizer,  402 

as  stomachic,  358 

in  cancer,  479 

in  gastritis,  422 
Organic  disturbance  of  digestion,  3 
Orientals,  bowel  habits  among,  300 
Origin  of  cancer,  461,  463 

Cohnheim's  theory,  463 
Orthoform  in  treatment   of   gastric 

ulcer,  367 
Ova  of  flies  in  stools,  103 

of  flukes,  99 

of  hookworm,  102 
Ovary,  removal  of,  161 

right,  inflammation  of,  38 
Oxgall  enema,  251 

in  jaundice,  279 
Oxidation  of  foods,  322 
Oxyntin  in  antacid  states,  357 
Oxyuris  vermicularis,  88,  562 
Ozonized  turpentine,  60 


Packs  in  acute  dysentery,  277 

variety  of,  270 
Pad  for  pendulous  abdomen,  226 
Page's  test  for  tubercle  bacilli,  105 
Pain,    abdominal,  counter-irritation 
for,  216 
spice  plaster  for,  217 

after  eating,  145 

agonizing,  in  rectum,  495 

boring,  burning,  487 

colicky,  308 

due  to  hyperchlorhydria,  353 

from  enlarged  spleen,  40 

gastric,  relief  of,  367 

gnawing,  442,  487 

in  digestive  diseases,  6,  7 

in  gastric  cancer,  466 
ulcer,  454 

periodic,  6 

recurrent,  significance  of,  8 

relieved  by  food,  487 


Pain,  relieved  by  tincture  of  iodine, 
217 

varying  nature  of,  7 
Palpation,  examination  by,  13 

in  gastric  cancer,  468 

of  stomach,  145 
Pancreas,  tumors  of,  34 
Pancreatic  cysts,  34 

stones,  '^l 
Pancreatin,  action  of,  359 
Pancreon,  360 
Papain,  action  of,  359 
Paraffin,  liquid,  as  evacuant,  362 

as    protective    coat    to    foreign 
body,  483 

for  constipation,  555 

in  intestinal  stenosis,  513 
Paralysis,    intestinal,    due    to   large 
enemas,  551 

post-operative,  360 
Parasites,  animal,  in  intestines,  557 

as  cause  of  diarrhea,  517 
of  gastritis,  403 

in  feces,  74,  75,  84 

intestinal,  79 

quinine  enemas  for,  558 
Parasitic  origin  of  cancer,  461,  463 
Paresis,  bulimia  a  precursor  of,  385 

gastrointestinal,  186 
Paris,  siege  of,  animal  food  during,  286 
Pars  cardiaca,  carcinoma  of,  130 
Pars  inferior  duodeni,  contents  of,  68 

media,  callous  ulcer  of,  124 

pylorica,  defect  in  filling  of,  129 
old  contracting  ulcer  of,  124 
■  superior  duodeni,  contents  of,  67 
Passive  exercise,  219 
Pea  flour  as  substitute  for  milk,  341 
Pea-soup  stool,  105 
Pecuniary     loss     from     hookworm 

disease,  568 
Pegnin,  447 
Pellagra,  ameba  in  stODls  of,  82,  536 

associated  with  amebic  dysen- 
tery, 82 

diagnosis  of,  10,  536 

diagnosticated  from  amebiasis, 
536 

diarrhea  of,  72,  518 

effluvia  from,  304 

kerosene  oil  injections  in,  533 
Pelletierine  for  tapeworm,  371,  560 
Pelvis,  inflammation  in,  247 
Pendulous   abdomen,   malign  influ- 
ence of,  222 
Penetrating  gastric  ulcer,  139 
Penzoldt's  tables,  330 
Pepsin  in  stomach  contents,  48 

test  for,  55 

value  of,  356,  359 


590 


INDEX 


Pepsinia,  normal,  56 

Peptic  ulcer,  440 

Peptone  in  gastric  contents,  55 

preparations,  328 
Peptones  significant  of  cancer,  472 
Percussion,  auscultatory,  19 

douche  to  spine,  276 

in  gastric  cancer,  468 

of  stomach,  17 

sounds,  18 

value  of,  13 
Perforation  of  duodenum,  acute  and 
subacute,  490 
chronic,  491 
diagnosis  of,  490 

of  stomach,  443,  444,  456 
Peripancreatic  cysts,  34 
Periproctitis,  497 

diagnosis  of,  498 
Peri-rectal  spaces,  mucous  channels 

.in,  499.  503 
Peristalsis,  and  the  emotions,  294 

exaggerated,  303 

in  dilated  stomach,  17 

in  gastric  cancer,  467 

increased    by    faradic    current, 
206 

intestinal,  produced  by  cathar- 
tics, 360 

promotion  of,  554,  556 

reversed,  186,  345 

stimulation  of,  246,  249 
electrical,  205 

visible,  12,  17,  152,  427 
Peristaltic  unrest,  12,  381 

hydrotherapy  in,  280 
Peristole,  disturbance  of,  429 
Peritonitis,  acute,  165 

from  pus  tubes,  546 

general,  from  infection,  409 

tubercular,  33 
Personal  equation,  306 

relations  between  physician  and 
patient,  4 
Personality  of  patient,  i 

of  physician,  306 

sub-conscious,  294,  295 
Perspiration  about  anus,  498 

production  of,  274 
Pertussis  belt,  223 
Pessimism  from  dyspepsia,  2 
Petroleum,  liquid  preparation  of,  555 
Pharynx,  clonic  spasm  of,  301 

obstructed,  feeding  in,  348 
Phenacetin  for  neuralgia,  369 
Phenolphthalein  as  a  cathartic,  361, 

555 
Phenomenon,  intestinal,  303 
Philippines,    amebic    dysentery    in, 

536 


Phlegmonous  gastritis,  408 

mortality  in,  409 
Phobias,  288 
Phosphate  crystals  in  feces,  74 

of  soda,  363 
Physical  bankruptcy,  290 

examination  of  patients,  10 

wretchedness    without    known 
cause,  413 
Pile-bearing  area,  498 
Pills,  inert,  profuse  catharsis  from, 

295 
Pin-worms  in  the  rectum,  371 
Placebo,  antacid,  355 

benefits  of,  306 
Placenta,  elements  from,  472 
Plant  parasites,  103 
Plaster  jacket   as   cause   of  gastric 

dilatation,  435 
Poison,  corrosive,  effects  of,  407 
Poisoning,  emesis  in,  366 

food,  516 

from  thymol,  371,  569 

gastric  lavage  in,  185 

ptomaine,  406 
Politzer  bag,  180 

Polynuclear  cells,  percentage  of,  164 
Pomegranate  root  for  tapeworm,  370, 

560 
Pork,  raw,  eating  of,  93 

tapeworm,  89 
Post-nasal  catarrh,  63,  417 
Posture  of  patient,  438 
Potato  remains  in  stools,  73 
Pouches  in  stomach,  145 
Poultices  for  relief  of  pain,  216 
Powder-blower,  243 
Pratt's  speculum,  240 
Precision  of  diagnosis,  danger  in,  313 
Predigested  foods,  337 

value  of,  338 
Pregnancy  and    the    stomach-tube, 
170 

test  for,  472 

vomiting  of,  223 
Pressure  changes  in  stomach,  261 

intra-abdominal,  433 
significance  of,  8 

of  overloaded  stomach,  435 

on  epigastrium,  388 

-point  in  stomach,  124 
movement  of,  124 

spots,  39 
Priessnitz  applications,  450,  451 
Primiparse,  abdomen  of,  427 
Privy  for  rural  locality,  568 

tub  system,  566 
Proctitis,  494 

acute  catarrhal,  241 
diagnosis  of,  495 


INDEX 


591 


Proctitis,  atrophic,  242 

chronic,  498 

exacerbations  in,  due  to  catch- 
ing cold,  497 

mucus  exudate  in,  497 

treatment  of,  496 
Proctoclysis,  247,  256,  438 

drop  method  of,  257 
Proctoscope,  pneumatic,  236 

Tuttle's,  242 
Proglottides  of  tapeworm,  88,  561 
Prognosis,  gloomy,  305 
Prolapse  of  organs,  224 

rectum,  495 
Propeptone  in  gastric  filtrate,  55 
Prophylaxis  of  chronic  gastritis,  417 
Proprietary  foods,  336,  339 

nutritive  material  in,  338 
Prostate,  palpation  of,  235 
Prostration  in  gastritis,  406 
Protective  barrier,  formation  of,  in 

ulcer,  490,  491 
Protein  catabolism,  265 

daily  intake,  318,  320    ' 

diet,  421 

digestion,  262,  267 

-fat  diet,  428 

putrefaction,  304,  364 

ration,  low,  321 
Proteins,  foreign,  disintegration  of, 
472 

value  of,  to  the  body,  316 
Protozoa  as  cause  of  dysentery,  79 

in  intestines,  557 

in  sputum,  80 

in  stools,  74 
Pruritus  ani,  507 
Pseudo  gall-stones,  77 

-health-teachers,  298 

-invalids,  229 
Psoas  abscess,  39 
Psychic  diarrhea,  520 

difficulty  in  swallowing,  6 

effect  of  bizarre  treatment,  203 
of  exploratory  operation,  168 

impulses,  digestive,  335 

indigestion,  6,  276,  377 
in  literature,  284 
treatment  of,  291 

influence,  209,  270 

of  electrovibration,  213 
over  motor  functions,  292 

stimulant,  219 
Psychoanalysis,  313 
Psychotherapy,  218     353 

applied  to  indigestion,  305 

in  cancer,  481 

in  cardiospasm,  382 

in  constipation,  553 

in  digestive  neuroses,  402 


Psychotherapy,    in   gastro-intestinal 
diseases,  282 
in  regard  to  diet,  307 
in  rest  cure,  312 
Ptomaine  poisoning,   406 
Ptyalin,  action  of,  58,  261,  335,  359 
Pulmonary   tuberculosis,   advanced, 

171 
Pumpkin  seed  for  tapeworm,  560 
Purgation,  reaction  from,  554 
Purgatives,  active,  554 
unwise  use  of,  497 
Pus  in  stools,  494 
Putrefaction,  intestinal,  266,  321 
Pyloric  dilator,  383,  434 

obstruction  from  ulcer,  456 
stenosis,  131,  137 
acquired,  431 
congenital,  431 

treatment  of,  432 
from  gall-bladder    adhesions, 

135 

Pylorus,  carcinoma  of,  117 
diagnosis  of,  118 

constriction  of,  478 

displacement  of,  123 

elevation  of,  by  corset,  226 

obstruction  of,  427 

palpation  of,  in  a  child,  33 

paralysis  of,  129 

patency  of,  430 

patulous,  183 

relaxed,  342 

resection  of,  476 
Pylorospasm,  15,  118,  124,  127,  383, 

431 
a  cause  of  long  food  retention, 

127 
and  lesion  of  stomach  wall,  124 
with  hyperacidity,   118 
with  organic  stenosis,  394 
Pyorrhea     alveolaris     a     cause     of 
catarrhal  gastritis,  410 
in  catarrhal  gastritis,  417 
Pyrosis,  276 

Q 

Quassia  for  worms,  562 
Quinine  enemas,  558 

R 

Racial  immunity  to  effects  of  disease, 

564 
Radio-diagnosis,  difficulties  in,  151 

of  biliary  calculi,  146 
Radiograph,  rectal,  499,  503,  505 
Radiographs  of  tumors,  474 
Radium  therapy,  211 

treatment  of  cancer,  479 


592 


INDEX 


Raisins  and  rice  test-meal,  442 
Rats  and  mice  as  food,  287 
Reading  as  aid  to  defecation,  297 
Rectal  ampulla,  235 

examination,     advisability     of, 

233 

feeding,  446 

in  antiquity,  344 
foods  utilized  in,  345 
time  limit  of,  345 
mucosa,  erosions   and   ulcers 
of,  242 
inspection  of,  241 
local  applications  to,  243 
sinus,  local  treatment  of,  508 
tube,  double-current,  247 
Rectoscope,  511 

Rectum,  burrowing  of  channels  in, 
498 
caloric  absorption  by,  345 
examination  of,  digital,  234 

instrumental,  235 
impacted,  275 
inflation  of,  236,  240 
irrigation  of,  507 
irritable,  347,  348,  495 
lavage  of,  74 

pathologic  changes  in,  498 
sensitiveness  of,  348 
ulceration  of,  243,  511 
worms  in,  562 
Recuperative  power,  305 
Red  meat,  prohibition  of,  452 
Reflex  diarrhea,  521 

intestinal  disturbance,  495 
"Regulin"    for     constipation,    362, 

552 
Regurgitation  of  food,  7 
Reichmann's  disease,  393,  395.     See 

also  Gastrosuccorrhea. 
Relish  of  food  under  necessity,  286 
Remissions  in  digestive  diseases,  6 
Rennin,  absence  of,  57 
deficiency  of,  57 
normal  content  of,  57 
Resection  of  intestines,  168 
Residue,  diet  leaving  little,  329 

seven-hour,  162 
Resistance  to  disease,  315 
Rest  cure,  311 

for  anorexia  nervosa,  386 
peristaltic  unrest,  381 
Retching  in  alcoholic  gastritis,  424 
Retention  enema,  450 

of  food  in  stomach,  127,  145 
Rhabdomena  strongyloides,  95 
Rhubarb,  effects  of,  554 
Rice  and  raisins  supper,  431 
Rieder  test-meal,  118,  152,  443 
Riegel's  test-dinner,  44 


Rigg's  disease,  417 
Roentgen  ray   in   diagnosing   hour- 
glass stomach,  140 
in  examination  of  abdomen, 

13 

of  esophagus,  no 
of  stomach,  117 
Rose  abdominal  belt,  228,  230,  231, 
232 
in  gastric  cancer,  478 
in  mucous  colic,  399 
in  pyloric  stenosis,  433 
Round  worms,  infection  hy,  561 
Rubbing,  abdominal,  221 
Rubner's  experiments  with  foods,  322 
Rugse,  distortion  of,  444 
Ruhrah's  diet  in  gastritis,  421 
Rumbling,  intestinal,  303 
Rumination,  383 

Russo-Japanese  War,  sanitary  pre- 
cautions in,  526 


Saline  enema,  251,  257 

infusions,  349 

laxatives,  363 
Saliva,  lack  of,  6 

mucin  constituents  of,  63 
Salivary  digestion,  261,  335 

glands,  disease  of,  359 
Sanatorium,  rest  in,  311 

treatment  of  diarrhea  in,  523 
Sand,  concretions  resembling,  77 

intestinal,  78 
Santonin  for  worms,  88,  371,  562 
Sarcinse  in  benign  stenosis,  466 

in  dilated  stomach,  104 
Sarcoma,  inoperable,  480 

of  stomach,  diagnosis  of,  463 
Satiety,  sense  of,  in  cancer,  465 
Scalding,  gastric  sensation  of,  487 
Scar  tissue,  244 
Schmidt  and  Strasburger's  test-diet, 

70 
Scirrhous  carcinoma,  462 
Scirrhus,  deep  circumscribed,  118 
Sclerosis  of  stomach,  476 
Scotch  douche,  268,  270 
Scratching  percussion,  19,  468 
Scybala  in  colon,  524 
Scybalse,  pressure  of,  492 

prevention  of,  552 
Seasickness  relieved  by  belt,  223 

relieved  by  medinal,  368 
Secondary^  stomach,  67 
Secretagogues,  283 
Secretin  in  gastritis,  422 
Secretion,  inhibition  of,  370 

psychic,  282 

stimulation  of,  422 


INDEX 


593 


Secretory  glands,   gastric,    stimula- 
tion of,  392 

neuroses,  387 
Sedatives,  gastric,  366,  367,  380 

intestinal,  366 
Senile  achylia,  357 
Sensory  neuroses,  384 
Sepsis,  proctoclysis  in,  256 
Serum  in  hematemesis,  369 

rabbit  or  horse,  369 

test  for  cancer^  472 

transuded  into  bowel,  520 
Sexes,  frequency  of  cancer  in,  460 
Shadow  from  stomach,  139 
Shambles,  thought  of,   as  cause  of 

nausea,  284 
"Sham  meals"  in  case  of  dog,  293 
Shell-fish,  idiosyncrasy  to,  287 
Shiga's  bacillus,  108,  526 
Shock,  influence  of,  380 

post-operative,  256 
Sigmoid  flexure,  cancer  in  region  of, 

39 

Sigmoid,  kinking  of,  155 

lavage  of,  74 

stenosis  of,  512 
Sigmoiditis,  241,  497 
Sigmoidoscope,  238,  511 

Tuttle's  pneumatic,  239 
Simple  life,  446 
Sinking  spells,  1 1 
Sinus  irrigator,  Albright's,  244 
Sinuses,  rectal,  501 

burrowing  of,  498 

irrigation  of,  508 
Sitophobia,  11,  307,  380,  388 

in  dysentery,  533 

study  of,  287 
Sitz-bath    before     sinus    irrigation, 

508 

in  chronic  dysentery,  278 

in  nervous  dyspepsia,  277 
Sizzling  sounds,  145 
Skiagram  showing  bismuth,  139 
Skin,  appearance  of,  as  a  symptom, 

ID 

carcinoma  from  X-rays,  461 
dry    and    scaly,     as    cause    of 

diarrhea,  518 
jaundiced,  relief  of,  279 
Sloughs  in  dysenteric  stools,  528,  536 
vSmell,  offensive,  a  cause  of  nausea, 

284 
Smoking  as  cause  of  gastritis,  410 

moderate,  418 
"Snail  stomach,"  444 
soup  in  Italy,  286 
vSoap  suppository  as  aid  to  defeca- 
tion, 297 
Sodium  as  intestinal  antiseptic,  365 

38 


Soldiers,    nervous   diarrhea   among, 

396,  520 
Solid  food,  intolerance  of,  308 
Sounds,  deglutition,  22 

gurgHng,  21,  23 

splashing,  21,  145,  412 
Soups,  chemic  composition  of,  327 
Spanish-American    War,    dysentery 
in,  525 
typhoid  fever  in,  525 
Spasm,  pyloric,  342 
Spastic  constipation,  545 
Speech,  slow,  in  hookworm  disease, 

566 
Spice  plaster,  217 
Spices  and  condiments,  410,  420 
Spinal  douche,  272 
Spine,  duodenum  to  right  of,  545 

faradization  of,  272 

ice-bag  to,  270 

percussion  douche  to,  276 
Spirillum  cholerae  Asiaticse,  106 
Splanchnoptosis,  231 
Splashing  sound  in  atonic  stomach, 

4-7 
Spleen,  enlargement  of,  35,  38 

palpation  of,  31 

Splenic  flexure  of  sigmoid,  kinking 

of,  155 
"Spoiled  stomach,"  304 
Spray  for  stomach,  203 
Sputum,  protozoa  in,  80 

swallowed,    tubercle   bacilli   in, 
105 
S.  S.  enema,  250,  451 
Stagnation,  fermentation  from,  354 
Starch  and  opium  enema,  347 
digestion,  57,  359 
a  factor  in  a  murder  case,  57 
Starvation,  chronic,  290 
diet,  337,  446 
from  a  "diet,"  380 
-  slow,  mistaken  for  indigestion, 

307 

Static  electricity,  209 

Steapsin,  test  for,  66 

Stenosis  of  esophagus,!  12 
of  intestines,  511,  544 
of  pylorus,  117,  245,  465 
old,  129 

Stenotic  dilatation  of  the    stomach, 

15,  17 
non- malignant,  434 
surgery  in,  434 
Stercoral  diarrhea,  treatment  of,  522 
SteriUzation  of  food,  water,  etc.,  538 
Stomach,  absorption  of,  414 
acidity  of,  200,  411 

with  constipation,  200 
adhesions  in,  140 


594 


INDEX 


Stomach,  aspiration  of,  45,  413 

atony  of,  129,  201,  205 

auscultatory  percussion  of,  19 

auto-lavage  of,  365 

bleeding  into,  145 

bucket,  211,  479 

cancer  of,  460 

carcinoma  of,  115 

catarrh  of,  411 

conditions  of,  indicating  lavage, 
199 

concentration    of    thoughts    on, 
290 

contents,  aspiration  of,  413 
chemical  examination  of,  44, 

48,470^ 
examination  of,  after  hemor- 
rhage, 442 
expression  of,  180 
in  duodenal  ulcer,  488 
microscopic  inspection  of,  46 
reaction  of,  49 
strata  of  food  in,  262 

delicate,  404 

diffuse  contraction  of,  130 

dilatation  of,  15,  127,  137,  272 

distention  of,  145,  300 

distdrted,  475 

douche,  203 

examination    of,    by    artificial 
distention,  17 

fasting,  examination  of,  389 

fermentation  in,  199,  200 

foreign  bodies  in,  48 1 

gaseous  distention  of,  16 

gummatous  masses  in,  475 

hook  form  of,  123 

horn-shaped,  123 
contracted,  121 

hour-glass  contraction  of,  140 

hypertonicity  of,  123 

illumination  of,  41 

inflation   of,   by    carbonic   acid 
gas,  20,  21 

irrigation  of,  188 

irritable,   use   of   nutrient   ene- 
mata  in,  348 

lavage  of,  190,    199,  200 

local  treatment  of,  203 

malignancy  of,  feeding  in,  348 

motility  of,  117,  414,  444 

motor  functions  of,  205 
visible,  292 

normal,  130 

obstruction  of,  146 

of  irregular  form,  183 

outlining    of,    by    the    use    of 
water,  20 

overloading  of,  435 

percussion  of,  145 


Stomach,  perfect  rest  for,  343,  348 
peristaltic  unrest  of,  381 
powder-blower,  204,  459 
ptosed,  162 
puncture  of,  408 
redilation  of,  437,  438 
residue,  six-hour,  131 
rest,  diet  for,  448 
secretion  of,  26 
secreto'ry  functions  of,  205 
sensory  disturbance  of,  333 
shortening  of,  130 
shrinkage  of,  123 
sickle-shaped  residue  in,  129 
snail-shaped,  123,  124 
sounding  of,  21 
suspension  of,  163 
time  of  food  retention  in,  127, 

331 

-tube,  buckling  of,  174 

choice  of,  173 

contraindications  for,  170 

habit,  II 

horror  of,  184 

idiosyncrasy  against,  172 

openings  in,  174 

passage  of,  2^,  176 

swallowing  of,  481 

use  of,  170,  190 

Einhorn's  method,  176 
in  anorexia  nervosa,  386 
tumors  of,  33 

ulcer  of,  129,  139,  439,  440 
vibration  of,  213 
visible  hemorrhage  from,  451 
walls,  massaging  of,  206 
washing  out  of,  1 1 
whistle,  21 
withdrawal  of,  183 
worms  in,  88,  561 
Stomachics,  358 
Stomatitis,  painful,  529 
Stones,  pancreatic,  77 
Stools,  ameba  in,  494 
bloody,  79,  105 
disinfection  of,  538 
in  Asiatic  cholera,  107 
in  diarrhea,  520 
microscopical    examination    of, 

74 

of  small  caliber,  512 

ova  of  hookworm  in,  565 

parasites  in,  557 

pencil-shaped,  545 

scant,  in  tumor,  544 

shape  of,  549 

straining  of,  559 
Straining  at  stool,  496 
Strata  of  food  in  stomach,  262 
Strawberry  hairs  in  feces,  565 


INDEX 


595 


vStreptococcus  of  erysipelas,  480 

infection  in  stomach,  409 
Stricture  of  esohagus,  308 
dilation  of,  309 

of  intestines,  168 

of  small  intestine,  362 
Strictures,  multiple,  over  several  feet 

of  intestines,  514 
Strongyloides  intestinalis,  95 

detection  of,  in  stools,  96 

stercoralis,  565 
Styptics,  369 

Succussion  sound,  23,  437 
Sufferers,  unhappy  class  of,  402 
Sugar,  chemic  composition  of,  327 
Supporters,  abdominal,  223,  227 
Suppository,  belladonna,  367 

food,  349 

glycerin,  297,  552 
Suprarenal  capsules,  growths  in,  35 
tumor  of,  35 

gland  extract,  459 
Surgery,  cases  requiring,  159 

in  cancer  of  stomach,  464 

in  gastric  ulcer,  456 

in  mucous  colic,  400 
Swallowing  of  mucus,  63 
Symptoms,  general,  significance  of,  9 

misleading,  68 
Syphilis  simulating  cancer,  475 
Syphilitic  ulcers,  494 

T 

Table  for  rectal  therapeutics,  234 

good  cheer  at,  310 
Tachyphagia,  334 
Tact,  exercise  of,  307 
Tffinia  echinococcus,  92 

mediocanellata,  88 

nana,  92 

saginata,  90 

solium,  88,  89 
growth  of,  90 
Taka- Diastase,  359 
Tannates,  preparations  of,  369 
Tannigen  for  diarrhea,  524 

in  dysentery,  532 
Tapeworm,  88 

anthelmintics  for,  370,  558 

beef,  90 

diagnosis  of,  561 

from  eating  fish,  92 

head  of,  expulsion  of,  558,  560 

in  America,  89,  90,  91 

male  fern  as  specific  for,  558 

pork,  89 

segments  of,  in  feces,  88,  89,  561 
Tartar  emetic,  366 
Tea  as  an  irritant,  46 

overindulgence  in,  410 


Teeth  and  mastication,  336 

good  condition  of,  417 
Temperament,  study  of,  3 
Tenderness,  areas  of,  in  gastric  ulcer, 
40 

epigastric,  31 
Tenesmus,  rectal, relief  of,  277,  532 
Test,  Boas'  resorcin-sugar,  50 

-breakfast,  settling  into  layers, 

389 
-diet,  difficulties  of,  71 
modified,  71 
of  Schmidt  and  Strasburger, 

70 
requirements,  69 
for  acetic  acid,  55 
for  bile,  63 
for  lactic  acid,  53 
for  occult  blood,  59 
for  pepsin,  55,  56 
for  pregnancy,  472 
free  hydrochloric  acid,  49 
Gunsburg's  phloroglucin  vanil- 
lin, 49 
-meal,  22 

as  aid  to  diagnosis,  68,  175 
double,  112,  117 
extraction  of,  175 
Riegel's,  44,  46 
serum,  for  cancer,  472 
-stool,  recognition  of,  71 
therapeutic,  in  gastric  neuroses, 

368,  380 
Toepfer's  quantitative,  50 
Thirst,  relief  of,  450 

severe,  437 
Thread-test,  491 
Throat,  insensitiveness  of,  175 
Thymol,    danger   in   absorption   of, 

371,  569 
in    hookworm    treatment,    568, 

569 

poisoning,  371 
Tissue  formation  in  proctitis,  497 
Toast  and  tea  diet,  290 
Tobacco,  black,  chewing  of,  418 
Toepfer's  quantitative  test,  50 
Tongue,  appearance  of,  in  disease,  12 

cleansing  of,  343 

sensitiveness  of,  172 
Tonic  prescriptions,  372 
Tonics,  bitter,  358 

local  and  general,  371 
Topography  of  stomach,  15,  19 
Toxemia,  intestinal,  480 

gastric  analysis  in,  413 
Toxic  gastritis,  403,  407 

treatment  of,  408 
Toxin  produced  by  hookworm,  564 

by  parasites,  557 


596 


INDEX 


Toxins,  effect  of,  on  gastric  wall,  436 

intestinal,  flushng  out  of,  246 
Toxogenic  decomposition,  330 
Transillumination  of  stomach,  41 

in  gastric  cancer,  468 
Transverse  colon,  ptosis  of,  544 

tumors  of,  37 
Traumatism  as  cause  of  cancer,  461 

tumor,  461 
Treatment,     importance     of     early 

institution  of,  307,  400 
Trematodes,  97 
Tremor,  alcoholic,  425 
Trichina  spiralis,  93 
Trichinella  spiralis,  94 
Trichiniasis,  93,  563 

treatment  of,  563 
Trichiura,  intestinal,  94 
Tricocephalus  dispar,  93,  563 

enormous      multiplication      of, 

563 

treatment  for,  564 
"Trifid  stomach,"  140 
Triturating  power  of  stomach,  261 
Tropical  dysentery,  526 
Trunk  pack,  270 
Trypsin,  test  for,  66 

treatment  of  cancer,  479 
Tryptophan,  470,  471 
Tube,  irrigating,  removal  of,  250 
Tubercle  bacilli  in  stools,  105 
Tubercular  ulcers,  493 
Tuberculosis  in  children,  105 

intestinal,  105 

of  stomach,  493 

pulmonary,  171 
Tumor  as  a  symptom,  145 

diagnosticated  from  gas,    18 

duodenal,  34 

fatty,  464 

fragments  in  feces,  79 

gastric,  differentiated  from  sple- 
nic, 36 

in  epigastrium,  33,  467 

in  left  lumbar  region,  38 

of  cecum,  493 

of  pancreas,  34 

of  right  kidney,  37 

of  stomach,  460 
apparent,  475 
benign,  464 

conditions  mistaken  for,  475 
Turck's  gyromele,  214,  215 
Turnip  greens  in  dysenteric  diet,  538 
Turpentine  for  tapeworm,  560 

ozonized,  60 

stupes,  216 
Tuttle's  operating  proctoscope,  242 
Tympanites,  165 

excessive,  247 


Tympany  of  stomach,  18,  19 
Typhoid  fever  in  warfare,  525,  526 
simulated  by  trichiniasis,  563 
stool,  pus  in,  105 


U 


Uffelmann's  test,  53 
Ulcer,  bleeding  from,  243 
callous,  123,  124,  129 
complicated    by     Reichmann's 

disease,  395 
cure,  491 

duodenal,  diagnosis  of,  485 
dyspeptic,  13 
esophageal,  25 
intestinal,  492 
near  pylorus,  474 
of  bowel,  treatment  of,  243 
of  lesser  curvature,  contracting, 

124 
of  stomach,  25,  129,  439,  440 
chronic,  456 
diagnosis  of,  441 
flat,  139 

Lockwood's  treatment  of,  450 
medical  or  surgical  treatment 

of,  444 
mortality  of,  444 
penetrating,  139 
perforation  of,  455 
surgery  in,  456 
X-ray  therapy  in,  456 
perforation  of,  219,  455 
radiographic  diagnosis  of,  443 
rectal,  235 
syphilitic,  494 
tubercular,  493 
Ulceration,  catarrhal,  492 

of  rectum,  511 
Ulcer-stenosis,  129 
Umbilical  region,  examination  of,  37 
Umbilicus,  irritation  of,  230 
Uncinaria  Americana,  100,  loi 
specific  against,  371 
duodenalis,  97,  100 
Uncinariasis,   564.     See   also  Hook- 
worm Disease. 
Underfeeding,  depression  from,  420 

indigestion  from,  307 
Uremia,  diarrhea  in,  519 
enemas  in,  247 
proctoclysis  in,  256 
Uremic  coma,  saline  infusion  in,  349 
Urine,  fluorescent,  43 

orange-yellow,  371,  562 
Uterus,  cancer  of,  460 

reflexed,  a  cause  of  diarrhea,  521 
worms  in,  88 


INDEX 


597 


V 

Vacation,  benefits  from,  380 
Vaccines,  mixed,  injection  of,  410 
Vacuum  bottle  for  irrigation,  257 
Vagina,  worms  in,  562 
Vegetable    astringents   in    diarrhea, 

524  ... 

Vegetables,   chemic  composition  of, 

326 

green,  in  hyperchlorhydria,  392 

Vermes  in  intestines,  557,  558 

Vertigo  on  arising,  412 

Vibration,  212 

Vibrators,  Vedee  and  Eureka,  212 

Vichy  water,  454 

Vicious  circle  in  digestive  diseases, 

314 
Vinegar  enema,  562 
Viscera,  abdominal,  support  of,  222 
Visceroptosis,  9,  163 
Vomit,  coffee-ground,  172,  431 

round  worm  in,  85 
Vomiting,    abdominal    support    for, 
223 

acute,  185 

as  a  symptom,  9 

due  to  carcinoma,  129 
duodenal  tube,  344 
mental  images,  284 

in  gastric  cancer,  466 

in  gastric  ulcer,  454 

in  peritonitis,  187 

in  robust  man,  from  grief,  285 

in  the  early  morning,  9 

in  acute  gastritis,  270,  404 

of  blood,  145,  439 

of  slimy  mucus,  412 

periodic,  186 

post-operative,  186 

projectile,  431,  437 

psychic  causes  of,  285 

relief  of,  366 
Vomitus,  coffee-ground,  465 

feculent  odor  to,  436 

foul  odor  to,  415,  469 

greenish,  436 

in  acute  gastritis,  404 

in  gastrosuccorrhea,  394 

with  occult  blood,  431 


W 


Warfare,  dysentery  the  bane  of,  525 

Wassermann  test,  476 

Water  as  preventive  of  constipation, 

550 
fourteen  glasses  of,  to  produce 

emesis,  365 


Water-drinking,  copious,  benefits  of, 
261,  264,  266,  423 
contraindicated,  272 
hot,  for  relief  of  nausea,  268 
in  food,  316 
with  meals,  260 

experiments  concerning,  263, 

266 
when  contraindicated,  262 
Waterlogging  with  soup,  340 
-trap  stomach,  143,  430 
Waters,  alkaline,  355 
Wave  of  improvement,  209 
Weight  increase  in  rest  cure,  313 
loss  of,  from  too  limited  diet,  393 
in  gastric  cancer,  467 
Whip-worm,     93,      563.     vSee     also 

Tricocephalus  Dispar. 
Whiskey,  cheap,  423 
craving  for,  424 
rye,  as  cause  of  gastritis,  411 
Whites,  poor,  hookworm  disease  in, 

564 
Worms,  hermaphroditic,  98 
nematode,  95,  561 
pin,  88,  102,  562 
round,  85,  370,  561 
eggs  of,  87,  561 
in  children,  561 
vomiting  of,  85,  561 
seat,  88 

thread,  88,  370,  562 
trematode,   97.   See   also   Fluke 
Worms, 

X 

X-ray  examination  for  gastric  cancer, 

473 
of  stomach,   15,   19,  22,   146, 
231 
phenomena,  gastric,  292 
therapy,  210 

in  gastric  ulcer,  456 
X-rays,  anodyne  effect  of,  210 
as  diagnostic  aid,  no,  158 
in  cardiospasm,  382 
in  inoperable  cancer,  479 
in  liver  abscess,  542 
in  treatment  of  ulcers,  2 1 1 
on  excised  stomach,  261 

Y 

Yeasts  in  stools,  103 
Yellow  urine,  371,  562 
vision,  562 

Z 

Zinc  oxid  plaster,  228 
Zone,  gall-bladder,  39 
pyloric,  39 


^4 


